Manager, Special Investigations Unit

Job Summary

The Manager of Special Investigations Unit (SIU) oversees multi-level staff and processes across multiple lines of business, and multiple claim platforms. In addition, this position works closely with external law enforcement officials, internal and external legal or compliance partners on escalated investigations or issues. 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. This position supports, manages and escalates identification of additional suspected fraud of health insurance claims and ensures claims are accurately handled. This team member will also be responsible for providing operational support in reporting, process improvements, coaching, internal quality, day to day Key Performance Indicators (KPI’s) and ensuring we meet and/or exceed performance metrics. The Manager manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports.

Duties

Provide leadership to investigators and be accountable for tracking KPI’s, metrics, recovery and savings, etc., provides feedback to staff on performance, resolves problems, provides guidance to team members when needed and takes necessary steps to address poor performance including corrective action up to termination.

Manage the day to day operations of the SIU by leading team of investigators, driving key initiatives across the team to improve processes and generate incremental F&A opportunities, and executing the overall strategic direction of the SIU.     

Create, implement and improve operational changes through documentation and process flows that anticipate needs and help in development of solutions to ensure all needs and issues are addressed promptly.

Work with multiple cross-functional LA Care teams and serve as the key resource on complex and critical issues.

Provide input to forecasting and planning activities for future state of the business staffing needs, adapt department plans and priorities based on operational needs of the business.

Direct team members in the area of ideation and vetting new concepts for building additional investigation opportunities or clearer review guidelines for cases.

Partner with compliance and regulators to make new policy or edits to mitigate fraudulent behavior.

Duties Continued

Work with Law Enforcement and regulators to appropriately support federal and state investigations or provide expert testimony during court proceedings.  

Drive process improvement and automation initiatives to enhance quality and productivity of outputs.

Manage staff, including, but not limited to: hiring staff, monitoring of day to day activities of staff, monitoring of staff performance, performance reviews, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, disciplinary matters for direct reports, among others.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:  

At least 5 years managing fraud investigations.

At least 3 years leading staff or supervisory/management experience.

Equivalency:  Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.

Preferred: 

Prior experience in a leadership role directly managing a team.

Experience in health care claim adjudication.

Skills

Required:
Demonstrated ability to manage multiple projects/initiatives and drive to completion.

Strong written and verbal communication skills and ability to communicate effectively with a client audience.

Intermediate working knowledge of MS Excel, Word, PowerPoint, SharePoint. Basic knowledge of MS Visio.

Moderate level of metrics and performance, reporting and understanding of trends and changes.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information