Manager, SIU Provider Investigations

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. 

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary

Point32Health is currently seeking highly motivated individuals to join our organization as a Manager within our Special Investigations Unit (“SIU”). The Manager is an essential team member of the SIU, responsible for supervising, and setting investigative strategies and priorities for a team of investigators focused on provider investigations.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Manages, develops, and motivates a team of provider investigators to ensure that all investigative leads are thoroughly and thoughtfully investigated
• Retains own caseload of high complexity investigation
• Works closely with the Director, SIU to develop, implement, and revise Point32Health’s investigative strategies, processes, and priorities, and effectively deploy investigators to meet those priorities
• Works with investigators to recommend appropriate disposition for investigations, including closure or corrective actions such as provider education, prepayment denial of claims, recovery of overpaid funds, and referrals to appropriate regulatory and law enforcement agencies
• Collaborates with the SIU’s Triage and Analytics teams to receive and prioritize referrals for investigation
• Represents the SIU on various internal working groups and committees, as needed
• Consults with various business unit leaders throughout Point32Health in order to obtain necessary evidence, cooperation, or clarification
• Develops a system involving key performance indicators to identify top performing staff;
• Other projects and duties as assigned.

Qualifications – what you need to perform the job

Certification and Licensure

• Clinical License, Certified Fraud Examiner (“CFE”) or Certified Professional Coder (“CPC”) designation a plus

Education

• Required (minimum): Bachelor’s degree or equivalent experience
• Preferred: Degree in a clinical or scientific field, business, computer science, or criminal justice.

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Experience

• Required: 5-7 years related experience in health insurance fraud investigations with at least two years in a senior investigative capacity. 3+ years related experience in audits/investigations.
• Preferred:

Skill Requirements

• Computer literacy is mandatory
• Excellent writing and analytical skills. Excellent investigative skills
• Excellent communication skills; must be able to communicate effectively with all levels of the organization and external customers. Excellent organizational skills. Familiarity with claims data querying systems.
• Total accuracy and attention to detail. Sound judgment and decision-making skills.
• Ability to successfully manage in a complex environment.
• Ability to manage and be directly responsible for multiple projects running simultaneously.
• Coaching, mentoring and management skills. Relationship building skills required.
• Must be able to work cooperatively in a team environment. Sense of humor.

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

$105,477.36 -$158,216.04

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization.  The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org