Director, Special Investigations Unit

About the role

The Director, Special Investigations Unit (SIU) will report to Sr. Vice President, Legal, Regulatory Affairs and Compliance and is responsible for supporting the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse.

Responsibilities

• Supports the prevention, detection, investigation, reporting, and when appropriate, recovery of money related to health care fraud, waste, and abuse.
• Performs accurate and reliable medical review audits, analyzes medical billing and codes, conducts confidential investigations related to compliance and regulatory requirements, documents the investigation through audit reports for interview and external review which document the findings, and reports issues of non-compliance in accordance with all laws and regulations.
• Reviews claims, looks for patterns of potential fraud, waste and/or abuse, and interacts with medical providers to request medical records for investigations.
• Manages audit processes, identifies potential fraud, and drives improvement in claims processing and reimbursement practices.
• Monitors staff and departmental productivity and efficiency, while adjusting workflows/staff assignments as needed.
• Serves as the liaison between clinical suppliers and the SIU as it relates to the Special Investigations Unit.
• Oversees insurance audits and investigations to ensure compliance with regulatory standards and protect the organization from financial risk.
• Manages audit processes, identifies potential fraud, and drives improvement in claims processing and reimbursement practices.
• Leads a team dedicated to investigating discrepancies and ensuring the integrity of insurance billing and reporting.
• Maintains current, in-depth knowledge of all Mass General Brigham Health Plan benefits, payment policies, provider network, configuration issues, Medicaid, and Medicare billing practices.
• Ensures that all SIU recoveries are processed accurately and in a timely manner in compliance with the MCO contracts.
• Coordinates with SIU team and gathers documentation related to requests from federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
• Provides oversight and review of the SIU referral intake and investigation process while giving guidance and direction to team on case investigation steps and actions.
• Works with leadership to maintain and revise policies and procedures, fraud, waste, and abuse plans, annual audit work plans, including department guidance memos, and educational materials.
• Identifies opportunities for improvement through the audit process and provides recommendations for system enhancement to augment investigative outcomes and performance.
• Accurately tracks, reports, and follows up on overpayments and recoveries.
• Leads the business requirement process and reporting to ensure proper and timely notification of case activity to the appropriate regulatory and/or law enforcement agency.
• Reviews all requests to open investigations, fraud referrals, corrective action plans and provider letters to ensure quality, accuracy, and clarity before submission to States for approval.
• Provides guidance to all investigators related to investigative case plans.
• Manages SIU work queues, as well as ensures SIU appeals are resolved timely.
• Collaborates with other department supervisors in the planning, development, and coordination of department specific and cross-functional initiatives.
• Facilitates team meetings as well as clinical supplier meetings and may lead and represent the SIU in various state FWA related regulatory meetings.
• Identifies, communicates, and escalates issues on a timely basis.
• Independently problem solves programmatic issues and implements appropriate solutions.
• Develops and oversees the production of standard KPI reports to monitor and report on overall department metrics and inventory management.
• Hold self and others accountable to meet commitments.
• Ensure diversity, equity, and inclusion are integrated as a guiding principle.
• Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.
• Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization.

Qualifications

• Bachelor's Degree required; Master's Degree preferred
• Health care coding certification (CPS or CCS) required
• Accredited Healthcare Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) required
• At least 5-7 years of experience in insurance audits, investigations, or a related field required
• At least 3-5 years of experience in a management role, preferably within healthcare required
• At least 5-6 years of experience in the Managed Care industry, Medicaid or Medicaid Managed care fraud detection unit preferred
• At least 6 years of experience in a health care payer setting and/or in a health care fraud control setting highly preferred