Special Investigations Unit

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The Special Investigations Unit (SIU) Program Manager will be responsible for developing, implementing, and managing a program that effectively prevents, detects, and investigates suspected fraud, waste, and abuse (FWA) across Peak Health's government and commercial insurance products. The role will help support the broader mission of Peak Health's payment integrity function. This candidate will manage the SIU program and vendors to ensure execution of the program. This position will work cross functionally with compliance, legal, claims, and accounting.

MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's degree or equivalent.

EXPERIENCE:

1. Four (4) years of experience as a managed care insurer focusing directly on payment integrity and special investigations.

PREFERRED QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certified Fraud Examiner (CFE).

2. Accredited Health Care Fraud Investigator (AHFI).

3. Certified Professional Coder (CPC).

EXPERIENCE:

1. Knowledge of Medicare, Medicaid and Commercial Coding rules and regulations.

2. Medical chart review/auditing.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Develop, maintain, and execute annual audit program.

2. Ownership of the SIU referral intake and triage process. Ensuring all referrals are investigated and followed up on as appropriate.

3. Perform investigations into suspected fraud, waste, and abuse, including all necessary planning, fieldwork, and reporting activities.

4. Leads process and reporting to ensure proper and timely notification of FWA activity to appropriate law enforcement and/or regulatory agency.

5. Identify opportunities for improvement through the audit process and provide recommendations for enhancement.

6. Creation and maintenance of departmental policies and procedures, educational materials, etc.

7. Works collaboratively with other departments to educate providers and vendors.

8. Lead and participate in meetings and workgroups with internal and external parties.

9. Track, report, and follow-up on overpayments and recoveries.

10. Participate in audit and regulatory reviews by providing documentation, summaries, and subject matter expertise related to SIU operations.

11. Collaborate with Compliance, Legal, Claims, and accounting departments to coordinate investigative activities, share findings, and support appropriate corrective or disciplinary actions.

12. Serve as a subject matter expert and internal resource on issues related to FWA prevention and detection.

13. Maintain current knowledge of healthcare fraud trends, enforcement priorities, and best practices in SIU program management.

14. Partner with the Compliance department to ensure SIU activities align with applicable federal and state laws, including CMS, Medicaid, and commercial payer requirements.

15. Manage relationships with external vendors, consultants, and technology partners to ensure service quality, performance, and contract compliance.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Sitting and working on a computer for several hours a day.

2. Must have visual and hearing acuity within the normal range.

3. Must have manual dexterity needed to operate computer and office equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

2. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written materials.

SKILLS AND ABILITIES:

1. Knowledge of provider payment methodologies, coding and billing, and clams processing.

2. Ability to use fraud/data mining tools.

3. Expertise using Microsoft Office products.

4. Excellent written and oral communication with internal and external partners.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2501 PHH Risk Admin

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