Senior Manager, Special Investigations Unit

Job Summary

The Senior Manager of Special Investigations Unit (SIU) will have responsibility for the Delegation Oversight of the Planned Partner (PP) and Participating Physician Group (PPG's) SIU representatives, vendors, contractors and other delegated entities. This position directly oversees PP/PPG SIU Managers and investigative personnel from PP/PPG's to ensure all PP/PPG's, vendors, contractors and delegated entities are in compliance with all fraud, waste and abuse (FWA) requirements implemented by Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). The position ensures the quality of FWA investigations. This position mentors the PP/PPG's in developing policy regarding FWA and SIU Investigations. The Senior Manager is responsible for managing audits of these groups including review of pre-audit documents, conducting the audit, submission of findings to Delegation Oversight, conducting the exit conference, review of audit findings, submission of annual audit findings, determining if a Corrective Action Plan (CAP) is required and accepting or rejecting CAP response. Additionally, the Senior Manager manages the submission of monthly fraud reporting by the (49) PP/PPGs, ensures Federal and State regulatory reporting is submitted in a timely manner, organizes the Quarterly Healthcare Fraud Investigative Roundtable and organizes quarterly training for the cadre of PP/PPG SIU Investigators.   

The Senior Manager is responsible for managing a team of Healthcare Fraud Investigators, providing mentorship and guidance of complex healthcare fraud investigations across multiple lines of business. In addition, this position works closely with external law enforcement officials, internal and external legal or compliance partners on escalated investigations or issues. This position manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. 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. The Senior Manager is responsible for managing and coordinating the implementation and administration of integrated program development strategies, policies, and procedures. This position supports, manages and escalates identification of additional suspected fraud of health insurance claims and ensures claims are accurately handled.

Duties

Primarily responsible for managing the Delegation Oversight of the Planned Partner (PP) and Professional Provider Group (PPG's) SIU representatives, vendors, contractors and other delegated entities.   

Responsible for the oversight, guidance and supervision of all Partner Managers and Investigators for all PP/PPGs SIUs. Responsible for developing, documenting and managing the investigative process with the PP/PPG's SIU teams and having open direct lines of communication with the PP/PPG SIU counterparts as well as vendors (Navitus, Beacon etc.) utilized by the L.A. Care SIU.    

Oversees the PP/PPG's in the development of policies pertaining to investigative guideline.  Responsible for supervising audits of the PP/PPGs and will hold them accountable for developing a functional SIU team and process. Manages monthly submission of fraud reporting and ensure all PP/PPG's submit timely regulatory reporting in compliance with Federal and State regulatory requirements.   
  
Establishes and oversees quarterly Healthcare Fraud Investigative Roundtables.  They will also be responsible for organizing the quarterly training of approximately PP/PPG SIU Managers and Investigators along with coordinating with outside agencies such as FBI, California Dept. of Justice, DHCS, the District Attorney's Office and the Attorney General's Office as well as subject matter experts who will provide training to enhance the capabilities of the PP/PPG SIU personnel.        

Responsible and provide oversight L.A. Care SIU Investigators, providing mentorship and guidance while overseeing the professional investigation of Fraud and Abuse (F&A) opportunities.  Develop goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees.

Serve as a key resource on complex and critical issues. Work with other departments within L.A. Care as well as coordinate with our Law Enforcement and Judicial counterparts on matters requiring their attention.
 

Duties Continued

Identifies and participates in the evaluation of strategic opportunities pertinent to the objectives of the department/ organization.  Oversees and coordinates the development of strategic programs on a project management basis, to include development of budgets and projections.  Manages and coordinates the implementation and administration of integrated program development strategies, policies, and procedures.  

Participates and contributes to the review and analysis of department's  financial information  to ensure all operations are within budget.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:  

6 years of experience in working with Plan Partner (PP) and Physician Provider Group (PPG) managing fraud investigations.

4 years leading staff or supervisory/ management experience.

Experience in managing multiple projects/ initiatives.

Prior experience in a leadership role directly managing a team.

Skills

Required:
Extensive knowledge in Medicare and MediCal rules, regulations.

Comprehensive understanding of the DHCS and CMS regulatory reporting requirements.  

Demonstrated strong project leadership and management skills. 

Ability to prioritize, plan and handle multiple tasks/demands simultaneously.  

Extensive Understanding of metrics and performance;  trends and changes.

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

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

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

Excellent leadership, team building and strategic thinking skills.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information