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This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Manager SIU
Location
Ohio
Posted
158 days ago
Salary
$83K - $132.8K / year
Seniority
Senior
Job Description
Manager SIU
CareSource
• The Manager, Program Integrity is responsible for managing Program Integrity requirements to include allegation intake, report analysis, triage, investigation, correction and reporting of fraud, waste and abuse. • Responsible for deposition, testifying in court in support of CareSource and Attorney General legal actions. • Manage all efforts of your investigative team focusing on thorough but timely investigations, highest impact prioritization, root cause identification, state and federal law enforcement collaboration, evidence development and investigative actions. • Drive and encourage innovative approaches to increase department effectiveness and efficiency. • Ensure quantitative and qualitative measures are used to meet performance objectives. • Develops and maintains key business contacts for investigative and SIU management purposes. • Ensure employees meet all state and federal contract requirements and follow department work processes. • Lead the Investigative team through investigative resolution including corrective action plans, terminations, Fair Hearings, recoveries, negotiations, mediation, and litigation. • Mentor employees on effective and through investigative case presentation. • Mentor direct reports including, coaching, development, performance feedback, disciplinary issues, annual performance evaluations and bonus review. • Lead and promote Employee Engagement. • Drive fraud identification through information sharing efforts, OIG Work Plan, Fraud Task Force participation and seminars. • Drive internal process and procedure changes by working with cross departmental teams to resolve identified internal system gaps that may present a FWA or financial risk to CareSource. • Take a leadership role in state and federal regulatory audits. • Proactively manage investigative team growth to meet new business requirements. • Take a leadership role in state and federal program integrity operations and fraud organizations such as NHCAA, HFPP, and ACFE. • Speak at national conferences on investigative efforts and fraud trends. • Develop and maintain an in-depth knowledge of the company’s business and regulatory environments. • Works closely with leadership to establish, communicate, and perpetuate the corporate vision, ensuring appropriate communication to all stakeholders. • Recognize and proactively manage operational dependencies and risks. • Maintains a framework of standards and best practice methodologies that are repeatable and evidence based. • Participate in strategic planning and implement action plans. • Perform any other jobs, as requested.
Job Requirements
- Bachelor of Science/Arts Degree in Criminal Justice, Medical/Health Care Field or related industry or equivalent years of relevant work experience is required
- Minimum of six to eight (6-8) years of investigative or health care experience is required
- Extensive experience in health care, legal, auditing, claims and/or investigative services is required
- Leadership/supervisory experience preferred
- Solid understanding of claims processing preferred
- Knows and uphold the provisions of the Corporate Compliance Plan
- Intermediate to advanced proficiency level of computer skills, including Microsoft Outlook, Word, Excel, Access, and Power Point
- Advanced troubleshooting and problem-solving capabilities
- Significant knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc. preferred
- Significant knowledge of medical insurance and/or state regulatory requirements.
- Certified Fraud Examiner (CFE), Certifications through America’s Health Insurance Plans (AHIP), Healthcare Anti-Fraud Association (HCAFA) and/or Managed Healthcare Professional (MHP), Accredited Health Care Fraud Investigator (AHFI), and/or Certified Professional Coder (CPC) are preferred.
Benefits
- We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
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