Senior Manager, Special Investigations Unit

The Senior Manager of Special Investigations Unit (SIU) will have responsibility for the Delegation Oversight of the Planned Partner (PP) and Participating Physician Group (PPG's) SIU representatives, vendors, contractors and other delegated entities. This position directly oversees PP/PPG SIU Managers and investigative personnel from PP/PPG's to ensure all PP/PPG's, vendors, contractors and delegated entities are in compliance with all fraud, waste and abuse (FWA) requirements implemented by Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). The position ensures the quality of FWA investigations. This position mentors the PP/PPG's in developing policy regarding FWA and SIU Investigations. The Senior Manager is responsible for managing audits of these groups including review of pre-audit documents, conducting the audit, submission of findings to Delegation Oversight, conducting the exit conference, review of audit findings, submission of annual audit findings, determining if a Corrective Action Plan (CAP) is required and accepting or rejecting CAP response. Additionally, the Senior Manager manages the submission of monthly fraud reporting by the (49) PP/PPGs, ensures Federal and State regulatory reporting is submitted in a timely manner, organizes the Quarterly Healthcare Fraud Investigative Roundtable and organizes quarterly training for the cadre of PP/PPG SIU Investigators.

The Senior Manager is responsible for managing a team of Healthcare Fraud Investigators, providing mentorship and guidance of complex healthcare fraud investigations across multiple lines of business. In addition, this position works closely with external law enforcement officials, internal and external legal or compliance partners on escalated investigations or issues. This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. Day to day management includes employee development, expense management, project management, business process improvement and identifying new investigation opportunities by collaborating with our internal/external analytics partners. The Senior Manager is responsible for managing and coordinating the implementation and administration of integrated program development strategies, policies, and procedures. This position supports, manages and escalates identification of additional suspected fraud of health insurance claims and ensures claims are accurately handled.

6 years of experience in working with Plan Partner (PP) and Physician Provider Group (PPG) managing fraud investigations.

4 years leading staff or supervisory/ management experience.

Experience in managing multiple projects/ initiatives.