Manager Special Investigations

BASIC FUNCTION

HCSC is looking for a dynamic individual to join its Fraud Investigations team! This position will be responsible for managing healthcare fraud and internal fraud investigations initially focusing on IL Medicaid; managing and training investigators as well as support staff; establishing and maintaining liaison with healthcare providers and law enforcement; and coordinating anti-fraud activities with other departments at HCSC.

Job Requirements

• Bachelor’s Degree in Criminal Justice, Finance or Accounting or related field and 5 years of direct law enforcement/investigation experience, including supervision of cases and investigators
• OR 9 years of direct professional work experience in the detection, investigation and/or prosecution of complex health care fraud schemes with the following professional certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), and/or Certified Fraud Examiner (CFE)
• 1 year of leadership or supervisory experience
• Strong organizational skills and results oriented with demonstrated leadership capabilities
• Keen analytical, interviewing, and investigative skills, with proficiency in data analysis and claims management systems
• Deep understanding of insurance fraud techniques, claims handling, and regulatory compliance
• Proficiency in anti-fraud analytics tools, case management software, and MS Office (Word, Excel, PowerPoint) as well as Workday

Preferred Job Requirements

• Master’s Degree
• Experience with IL Medicaid FWA investigations

Key Functions

• Develop and manage investigative group designed to detect, investigate, and refer health care fraud cases to law enforcement
• Ensure evidence collected, including documents and interview reports, are maintained in a manner to ensure integrity in court proceedings
• Ensure personnel are properly trained and managed in investigative techniques
• Prepare weekly investigative and activity reports
• Cookordinate with other HCSC departments concerning ongoing anti-fraud programs and procedures
• Develop and maintain sources of information needed to detect health care fraud
• Develop and maintain liaison contacts with law enforcement
• Direct and supervise sensitive investigations when appropriate
• Deal directly with HCSC customers on fraud matters when appropriate
• Conduct monthly file reviews and provide direction to investigators regarding investigative strategies and plans
• Cookordinate investigative activities with the Legal Department
• Ensure investigators are familiar and utilize health care fraud databases, including Fraud and Abuse Management System (FAMS)
• Comply with federal and state reporting and fraud investigation requirements
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies
• Maintain complete confidentiality of company business
• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested

Pay

Compensation: $92,700.00 - $167,500.00 Exact compensation may vary based on skills, experience, and location

Schedule

The role is hybrid flex and requires in-office visibility three days per week, working from home the other two days.