Director of Corporate Investigations/Special Investigations Unit
Description: The Director of Corporate Investigations reports directly to the Chief Compliance Officer and is responsible for the building and maintaining the strategic and tactical operation of the Enterprise Fraud, Waste and Abuse (FWA) Program.
The individual in this serves as the industry expert in health care Fraud, Waste and Abuse (FWA).
This individual conducts national and regional intelligence gathering and health care FWA threat analysis, serves as a liaison with local, state and federal law enforcement agencies specific to health care FWA, develops annual and quarterly anti-FWA work plans, serves as the Chair of the Corporate Fraud, Waste and Abuse Committee (FWAC) and Health Plan FWAC, serves as the Corporate lead for the National Health Care Anti-Fraud Association (NHCAA), develops all staffing models and resource planning, participates in vendor selection and vendor management for designated tools, directs a team of professional investigators and monitors their work and progress on cases, ensures unit compliance to state and federal laws and regulations, develops educational content for both internal and external use, drives financial impact through prevention, avoidance and recovery, works closely with the Corporate Legal team as FWA cases move forward, partners with state and federal agencies in prepping for potential prosecution or other corrective action and prepares reports for the Board of Directors on anti-FWA activities.
Ensures unit compliance to all state and federal requirements, including, but not limited to policies and procedures, Fraud Plans, annual fraud report filings and fulfillment of subpoenas, Request for Investigative Assistance (RIAs) and victim impact statements.
Ensures unit will deliver a and/or detailed report on investigative findings for referral to state or federal agencies to include, but not limited to, the MEDIC, DOI, FBI, HHS-OIG, MFCU, and local law enforcement.
Directs field operations to include surveillance as required.
Provides case updates to Senior Leadership on progress of investigations and coordinates with the Chief Compliance Officer (CCO) on recommendations and further actions and/or resolution.
Works cooperatively within the Enterprise structure to foster collaboration and partnership in maintaining a culture of compliance.
Provides the expertise to developers in ideation phase to build, generate, and revise routine and ad hoc detail and level reports, including written interpretation of analytic results and report automation.
Arranges and conducts meetings with providers, employees, business partners, regulatory agencies and law enforcement as required.
Develops and maintains contacts/liaison with law enforcement, regulatory agencies, task force members, other SIU staff and other external contacts involved in fraud investigation, detection, and prevention.
Support organizational needs by providing de and or testimony to support ongoing state, federal or legal proceedings.
Design, build and operationalize a pre-payment intervention program.
Design, build and operationalize a post-payment recovery program.
Works with Senior Data Analyst to develop an annual FWA Data Analytics Plan.
Provides the expertise for development of proprietary data mining queries, using advanced statistical analysis techniques, and statistical modeling to maximize the effectiveness of the FWA program.
Directs audits of claims, including probe and full statistical samples utilizing either random or targeted methodologies; then extrapolates results to universe.
Drives recoveries, prevention and cost avoidance.
Qualification: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE).
Certified Professional Compliance Officer (CPCO) or other Compliance credential.
Certified Professional Coder (CPC, CPC-A or CPC-H).
Minimum of 10 years of experience in investigations specifically related to healthcare anti-fraud efforts.
Bachelor s Degree.
The individual in this serves as the industry expert in health care Fraud, Waste and Abuse (FWA).
This individual conducts national and regional intelligence gathering and health care FWA threat analysis, serves as a liaison with local, state and federal law enforcement agencies specific to health care FWA, develops annual and quarterly anti-FWA work plans, serves as the Chair of the Corporate Fraud, Waste and Abuse Committee (FWAC) and Health Plan FWAC, serves as the Corporate lead for the National Health Care Anti-Fraud Association (NHCAA), develops all staffing models and resource planning, participates in vendor selection and vendor management for designated tools, directs a team of professional investigators and monitors their work and progress on cases, ensures unit compliance to state and federal laws and regulations, develops educational content for both internal and external use, drives financial impact through prevention, avoidance and recovery, works closely with the Corporate Legal team as FWA cases move forward, partners with state and federal agencies in prepping for potential prosecution or other corrective action and prepares reports for the Board of Directors on anti-FWA activities.
Ensures unit compliance to all state and federal requirements, including, but not limited to policies and procedures, Fraud Plans, annual fraud report filings and fulfillment of subpoenas, Request for Investigative Assistance (RIAs) and victim impact statements.
Ensures unit will deliver a and/or detailed report on investigative findings for referral to state or federal agencies to include, but not limited to, the MEDIC, DOI, FBI, HHS-OIG, MFCU, and local law enforcement.
Directs field operations to include surveillance as required.
Provides case updates to Senior Leadership on progress of investigations and coordinates with the Chief Compliance Officer (CCO) on recommendations and further actions and/or resolution.
Works cooperatively within the Enterprise structure to foster collaboration and partnership in maintaining a culture of compliance.
Provides the expertise to developers in ideation phase to build, generate, and revise routine and ad hoc detail and level reports, including written interpretation of analytic results and report automation.
Arranges and conducts meetings with providers, employees, business partners, regulatory agencies and law enforcement as required.
Develops and maintains contacts/liaison with law enforcement, regulatory agencies, task force members, other SIU staff and other external contacts involved in fraud investigation, detection, and prevention.
Support organizational needs by providing de and or testimony to support ongoing state, federal or legal proceedings.
Design, build and operationalize a pre-payment intervention program.
Design, build and operationalize a post-payment recovery program.
Works with Senior Data Analyst to develop an annual FWA Data Analytics Plan.
Provides the expertise for development of proprietary data mining queries, using advanced statistical analysis techniques, and statistical modeling to maximize the effectiveness of the FWA program.
Directs audits of claims, including probe and full statistical samples utilizing either random or targeted methodologies; then extrapolates results to universe.
Drives recoveries, prevention and cost avoidance.
Qualification: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE).
Certified Professional Compliance Officer (CPCO) or other Compliance credential.
Certified Professional Coder (CPC, CPC-A or CPC-H).
Minimum of 10 years of experience in investigations specifically related to healthcare anti-fraud efforts.
Bachelor s Degree.