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Special Investigations Unit Administrator
15 hours ago
Compliance Special Investigations Unit AdministratorThe Compliance Special Investigations Unit (SIU) Administrator provides administrative, operational, and regulatory support to DWIHN's SIU, which is responsible for identifying, investigating, and reporting potential Fraud, Waste, and Abuse (FWA) involving Medicaid-funded behavioral health services. This position plays a critical role in supporting DWIHN's compliance with federal and state Medicaid requirements, including PIHP contractual obligations with the Michigan Department of Health and Human Services (MDHHS), Centers for Medicare & Medicaid Services (CMS), and oversight agencies. The SIU Administrator ensures investigations are properly tracked, documented, reported, and audit-ready, while maintaining strict confidentiality and data integrity.Principal Duties And Responsibilities:Maintain SIU case files from intake through closure, ensuring documentation is complete, accurate, and compliant with DWIHN policies and procedures.Track investigation milestones, statutory and contractual timelines, and case dispositions using DWIHN systems, including CATS, CareConnect360, MHWIN, CHAMPS-related documentation, and internal SIU trackers.Monitor intake sources including internal referrals, anonymous reports, provider self-disclosures, recipient complaints, and external agency referrals.Ensure proper version control, labeling, and storage of investigation materials in accordance with DWIHN records-retention requirements.Support SIU compliance with applicable regulations, including but not limited to: 42 CFR 438.608 (Program Integrity), 438.610 (Prohibited Affiliations), and 455.2 (Fraud, Waste, and Abuse definitions).Assist with preparation and tracking of referrals, notifications, and disclosures to MDHHS, OIG, CMS, and law enforcement, as directed by Compliance leadership.Ensure all SIU activities align with DWIHN's PIHP contract, Compliance Plan, and Program Integrity policies.Prepare investigation files for internal audits, HSAG reviews, MDHHS site visits, and OIG requests.Maintain SIU logs and dashboards tracking key metrics such as: case volume and status, intake sources, days to closure, referral outcomes, recoupment amounts and corrective actions.Compile data for monthly, quarterly, and annual Compliance Committee, Risk Management Committee, and Board reporting.Assist in identifying trends, repeat issues, and emerging risks to support DWIHN's enterprise risk assessments and corrective action planning.Schedule and coordinate interviews, case review meetings, multidisciplinary work groups, and leadership briefings.Draft and format correspondence, case summaries, referral documentation, and internal memoranda related to SIU activities.Provide onboarding and administrative support to compliance specialist/investigators, including access coordination, training tracking, and workflow support.Serve as a liaison between SIU and internal departments including Claims, Provider Network Management, Finance, Legal, HR, Recipient Rights, and Quality.Handle highly sensitive investigative, personnel, provider, and member information with discretion and professionalism.Ensure compliance with HIPAA, 42 CFR Part 2, and DWIHN privacy and security policies.Maintain strict confidentiality of SIU investigations and related materials.Performs related duties as assigned.Knowledge, Skills And Abilities (KSA'S) Working knowledge of Medicaid FWA concepts and investigative workflows. Familiarity with Michigan Medicaid, PIHP contractual requirements, and MDHHS oversight expectations.
