Manager SIU - R11183

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Job Summary

The Manager, Program Integrity is responsible for managing Program Integrity requirements to include allegation intake, report analysis, triage, investigation, correction and reporting of fraud, waste and abuse.

• Responsible for deposition, testifying in court in support of Care Source and Attorney General legal actions
• Manage all efforts of your investigative team focusing on thorough but timely investigations, highest impact prioritization, root cause identification, state and federal law enforcement collaboration, evidence development and investigative actions
• Drive and encourage innovative approaches to increase department effectiveness and efficiency
• Ensure quantitative and qualitative measures are used to meet performance objectives
• Develops and maintains key business contacts for investigative and SIU management purposes
• Ensure employees meet all state and federal contract requirements and follow department work processes
• Lead the Investigative team through investigative resolution including corrective action plans, terminations, Fair Hearings, recoveries, negotiations, mediation, and litigation
• Mentor employees on effective and thorough investigative case presentation
• Mentor direct reports including coaching, development, performance feedback, disciplinary issues, annual performance evaluations and bonus review
• Lead and promote Employee Engagement
• Drive fraud identification through information sharing efforts, OIG Work Plan, Fraud Task Force participation and seminars
• Drive internal process and procedure changes by working with cross departmental teams to resolve identified internal system gaps that may present a FWA or financial risk to Care Source
• Take a leadership role in state and federal regulatory audits
• Proactively manage investigative team growth to meet new business requirements
• Take a leadership role in state and federal program integrity operations and fraud organizations such as NHCAA, HFPP, and ACFE
• Speak at national conferences on investigative efforts and fraud trends.
• Develop and maintain an in-depth knowledge of the company’s business and regulatory environments
• Works closely with leadership to establish, communicate, and perpetuate the corporate vision, ensuring appropriate communication to all stakeholders
• Recognize and proactively manage operational dependencies and risks
• Maintains a framework of standards and best practice methodologies that are repeatable and evidence based
• Participate in strategic planning and implement action plans
• Perform any other jobs as requested

• Bachelor of Science/Arts Degree in Criminal Justice, Medical/Health Care Field or related industry or equivalent years of relevant work experience is required
• Minimum of six to eight (6‑8) years of investigative or healthcare experience is required
• Extensive experience in healthcare, legal, auditing, claims and/or investigative services is required
• Leadership/supervisory experience preferred

• Demonstrated leadership qualities
• Support the development of effective working relationships with business partners
• Solid understanding of claims processing preferred
• Knows and upholds the provisions of the Corporate Compliance Plan
• Intermediate to advanced proficiency level of computer skills, including Microsoft Outlook, Word, Excel, Access, and Power Point
• Advanced troubleshooting and problem‑solving capabilities
• Effective communication and interaction skills
• Ability to formally present to a wide audience internally and at national conferences
• Ability to lead a team and achieve performance metrics
• Highest levels of ethics, integrity and professionalism
• Significant knowledge of government program compliance requirements – Medicare, Medicaid, Affordable Care Act (ACA), etc. preferred
• Significant knowledge of medical insurance and/or state regulatory requirements

• Certified Fraud Examiner (CFE), Certifications through America’s Health Insurance Plans (AHIP), Healthcare Anti‑Fraud Association (HCAFA) and/or Managed Healthcare Professional…