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Special Investigations Unit Manager

4 months ago

Dallas, Texas, United States Parkland Health and Hospital System Full time

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that's served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It's our passion.

Primary Purpose

Responsible for managing the operations of the Special Investigations Unit (SIU). Accountable for management of the investigation, detection and mitigation efforts related to provider, member, and/or prescriber fraud, waste, or abuse.

Minimum Specifications

Education

  • Bachelor's degree in Healthcare/Business Administration, Legal Studies, or related discipline required.
  • Master's degree in Healthcare/Business Administration, Legal Studies or related discipline preferred.

Experience Required:

  • Five (5) years of experience in managed care or healthcare compliance required.
  • Two (2) years of experience focused on fraud, waste, and abuse required.
  • Prior experience working with regulatory agencies such as CMS, HHSC, OAG, and OIG required.

Preferred:

  • Fraud, waste, and abuse experience in Texas Medicaid strongly preferred.
  • Prior supervisory experience preferred.

Equivalent Education and/or Experience

  • In lieu of a bachelor's degree, five (5) years of experience in a Federal or State Healthcare program may be considered.

Certification/Registration/Licensure

  • ACFE Certified Fraud Examiner (CFE), AAPC Certified Professional Coder (CPC) or any other AAPC recognized certification required.
  • NHCAA Accredited Health Care Fraud Investigator (AHFI) preferred.

Skills or Special Abilities

  • Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines.
  • Ability to Communicate complex information in understandable terms.
  • Excellent interpersonal skills with the ability to establish and maintain effective working relationships across and beyond the organization.
  • Demonstrated ability to lead organizational initiatives, accomplish results, and achieve measurable outcomes or goals.
  • Strong time management skills with the ability to handle multiple demands and respond to rapidly changing priorities.
  • Knowledge of investigative techniques along with the ability to organize, analyze, and effectively determine risk with corresponding solutions.
  • Solid understanding of claim billing codes, medical terminology, and healthcare delivery systems.
  • Strong knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid Programs.
  • Proficient computer and Microsoft Office skills.

Responsibilities

Operations

  • Manage the development and operation of an effective fraud, waste, and abuse program in accordance with CMS requirements and the Federal guidelines.
  • Works in collaboration with leaders throughout the organization, as well as external stakeholders, to prevent, detect and resolve fraud, waste, and abuse (FWA).
  • Development and oversight of effective processes for routine FWA monitoring, auditing, and identification of compliance risks
  • Collaborates with other departments to ensure compliance issues are appropriately reported for investigation and resolution.
  • Provide oversight of FWA investigations and resolution procedures, including but not limited to corrective action plans, terminations, appeals, recoveries, negotiations, mediation, and litigation.
  • Collaborate with subcontractors, regulatory, and law enforcement agencies to coordinate SIU activity; serve as representative for PCHP's SIU function in partnership with Legal team.
  • Ensure clear and specific policies and/or procedures related to compliance monitoring activities are in place.
  • Identify potential areas of FWA vulnerability and risk; work with PCHP leadership to develop and implement corrective action plans for resolution of identified issues providing guidance on how to mitigate risk going forward.
  • Provides direction in emergency or crisis situations.

Regulatory Compliance

  • Accountable for ensuring compliance with regulatory agencies and accrediting bodies.
  • Research, interpret, and provide guidance regarding regulatory requirements.
  • Use data mining and analytics to detect FWA.
  • Complete and file all required Medicaid filings and/or responses for FWA.
  • Conduct annual policy review including the FWA plan.

Fiscal Management

  • Operational responsible for the financial performance of assigned area(s).
  • Promote activities to achieve operational efficiency.
  • Manage the approved budget through frequent and regular monitoring. Implement written action plans to address variances adjusting strategies as necessary to meet budgetary targets.
  • Consider operational outcomes and financial implications when making recommendations to implement new programs or modify current programs.
  • Manage staffing levels within established targets.

Talent Management

  • Recruits and retains a quality workforce.
  • Accountable for orientation, ongoing education and training, and competency verification for all employees.
  • Ensure Human Resource metrics (i.e., retention, vacancy, engagement) meet established targets.
  • Promote and foster a diverse, highly engaged, and collaborative work environment within areas of responsibility. Utilize workforce metrics to monitor, identify, and respond to workforce trends.
  • Conduct regular meetings, inform team of changes in policy or procedure, and provide information regarding overall strategy and direction of the health plan.
  • Mentor, coach, and support direct reports with building teamwork, professional development, and education to achieve optimal performance and develop talent.
  • Ensure employee engagement survey participation rates and results meet established targets.
  • Mandatory requirements are complete and required credentials are current and in good standing.
  • Employee performance is monitored and managed. Consults with the Office of Talent Management as appropriate regarding disciplinary action.

Professional Accountability

  • Adhere to organizational policies, procedures, and guidelines.
  • Complete assigned training and annual health requirements timely.
  • Recognize and communicate ethical and legal concerns through the established channels of communication.
  • Demonstrate accountability and responsibility by independently completing projects and assignments on time and providing timely responses to requests for information.
  • Maintain confidentiality at all times.
  • Perform other work as requested that is reasonably related to the employee's position, qualifications, and competencies.

Job Accountabilities

  1. Identifies and analyzes the design of jobs, work processes, workflows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of PCHP.
  2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
  3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.
  4. Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
  5. Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of PCHP.
  6. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.

#LI-GC1

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. As part of our commitment to our patients and employees' wellness, Parkland Health is a tobacco and smoke-free campus.