Director, Special Investigations Unit - AHFI

About the role

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.

Responsibilities

• Lead and develop the SIU Infrastructure.
• Oversee and responsible for the activities of SIU for accurate and timely investigative cases.
• Manages and responsible for resolving complex investigative cases and/or issues to ensure accurate, cost effective, and compliant operations.
• Conduct FWA training/education with staff and departments across the organization which includes all portfolio companies (Welcome Health, Healthcare In Action, Homebase, myPlace Health).
• Develop FWA and protocols for the health delivery model for the portfolio companies.
• Manage the overall supervision, planning, organization, and execution of SCAN's fraud, waste, and abuse program.
• Works closely with the VP of Internal Audit regarding strategy.
• Leads and supports the activities of the SIU team to ensure accurate and timely audits and investigations.
• Interprets audit results and assists health plan executives in the development of appropriate action plans to address identified issues, including but not limited to financial recovery efforts.
• Makes sure vendors performing audit and recovery activities are doing so accurately and efficiently.
• Identifies and directs the implementation of qualified personnel with appropriate expertise, improved processes, and new technologies.
• Ensures compliance with all state and federal regulations for fraud, waste, and abuse, including but not limited to reporting obligations.
• In collaboration with Legal, responds to all legal inquiries including subpoenas and court appearances.
• Attends federal and state fraud meetings and industry events and training.
• Works closely with VP of Internal Audit with SCAN Group Board Compliance Committee materials related to FWA.
• Develops fraud risk assessment.
• Coordinates participation in FWA/SIU industry associations, coalitions, and stakeholder groups, leveraging participation in those organizations to support the FWA program.
• Builds and maintains strong relationships with federal and state regulators, investigatory units, and enforcement agencies.
• Helps lead a culture of compliance with applicable laws and regulations, corporate citizenship, and diversity, equity, inclusion, and belonging.
• Provides on-going guidance to senior and mid-level management at the portfolio companies with matters related to FWA.

Qualifications

• Bachelor’s Degree or equivalent experience
• 10+ years related compliance, FWA, and/or special investigation experience in managed-care or CMS.
• Prior experience working with regulatory agencies such as CMS, HHS, and OIG
• Risk Adjustment And Coding Experience/expertise Preferred.
• 3+ years of experience within healthcare industry, preferred.
• Certified Criminal Justice Specialist (CCJS), preferred
• Accredited Health Care Fraud Investigator (AHFI), Strongly preferred
• Certified Fraud Examiner (CFE), preferred
• Certified Healthcare Compliance (CHC), preferred

What's in it for you?

• Base Pay Range: $147,000-$190,000, Salary
• Work Mode: Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days
• Excellent 401(k) Retirement Saving Plan with employer match
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!