LOCATION: Remote – must live in or near Vaya’s catchment area. Incumbent in this role must live in North Carolina or within 40 miles of the NC border. Must have ability to travel to the Asheville NC office as needed.
GENERAL STATEMENT OF JOB
The Special Investigations Operations Manager works in collaboration with and under the direct supervision of the Special Investigations Director. The Special Investigations Operations Manager will direct, manage, and provide oversight of investigations assigned to Special Investigators. The Special Investigations Operations Manager must apply knowledge and expertise of North Carolina Medicaid healthcare services. This position requires oversight of the application of cutting-edge analytics tools, and robust processes to confront the ever-changing challenges of detecting and resolving fraud, waste, and abuse (FWA). The Special Investigations Operations Manager will conduct and assist with member, recipient and provider FWA interviews. This position requires a high, consistent, and frequent degree of team involvement to ensure efficiency, consistency, seamlessness, and optimum performance.
ESSENTIAL JOB FUNCTIONS
Operations Management:
- Develop strategies to create and maintain a special investigations unit that has the flexibility, knowledge, situational awareness, and capacity to successfully address the dynamic FWA environment
- Develop recommendations or intervention strategies to correct and/or prevent abusive practices, including proposals to recover inappropriately paid monies or to suspend or terminate program participation
- Manage the development and delivery of educational awareness and training programs for the organization and providers
- Assist with development and monitoring of the annual work plan and ensure all elements of the work plan are completed in a timely and accurate manner
- Oversee and coordinate the development of individual and team performance dashboards
- Coordinate proactive fraud leads and referrals generated using data analytic tools
- Coordinate special investigations in response to referrals
- Perform fraud investigation activities as needed
- Represent the Special Investigations Unit (SIU) on appointed committee(s) as directed by the Special Investigations Director
- Interpret applicable rules and regulations
- Interact and coordinate with governmental law enforcement and regulatory agencies as directed by the SIU Director
- Present provider review findings to internal and external entities as requested by the SIU Director
Supervisory:
- Directly supervise the unit Investigators
- Provide oversight of the investigations assigned to the Special Investigations Unit
- Provide ongoing staff development
- Develop and monitor direct supervisees individual performance indicators
Other duties as assigned.
KNOWLEDGE, SKILL & ABILITIES
- Knowledge of healthcare service definitions, service documentation, and service utilization requirements
- Knowledge of Local, State and federal laws and regulations pertaining to insurance and/or healthcare services
- Knowledge of medical coding, ICD-10, HCPCS, HIPAA, etc.
- Knowledge of medical records and documentation requirements
- Knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions
- Excellent decision-making abilities to determine the appropriate course of action during investigations and subsequent follow-up
- Ability to analyze data to track progress, support dashboard development, and develop reports that communicate the units progress to others
- Ability to prepare detailed and comprehensive reports, to present facts clearly, and to instruct others in new methods and procedures
- Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud Medicaid and Non-Medicaid programs
- Ability to provide effective consultation, education, and training to others
- Ability to establish and maintain positive and effective working relationship with others
- Ability to produce, understand and interpret complicated written material and verbal presentations
- Ability to work autonomously, exercising sound judgement and problem resolution skills
QUALIFICATIONS & EDUCATION REQUIREMENTS
Master’s degree in Human Services, Business, Criminal Justice, or related field required. Incumbent must have five (5) years of progressively professional experience in healthcare or insurance related matters along with:
- At least two (2) years of supervisory experience, with preference for experience coordinating projects across multiple departments;
OR
- Two (2) years of supervisory experience and two (2) years of healthcare auditing experience;
OR
- Two (2) years supervisory experience and at least two (2) years of experience in a healthcare organization, related law enforcement agency, or fraud investigation unit
Required licensure/certification: Licensed in North Carolina. Acceptable licensure includes HSP-PA, LCSW, LPA, LMFT, LCMHC, PhD or PsyD. Employee must maintain credentials including requirements for licensure (e.g., CEU’s).
Preferred licensure/certification: Preferred only - Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified Professional Coder preferred but not required.
PHYSICAL REQUIREMENTS
- Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
- Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
- Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
- Mental concentration is required in all aspects of work.
RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.
SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.
DEADLINE FOR APPLICATION: Open Until Filled
APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.
Vaya Health is an equal opportunity employer.
