Senior Manager – Special Investigations

Responsibilities

• Manage health care fraud and internal fraud investigations
• Manage and train investigators and support staff
• Establish and maintain liaison with health care providers and law enforcement
• Coordinate anti-fraud activities with other departments at HCSC
• Partner with Compliance, Legal, Audit, Provider Services, Clinical Operations, and external regulatory agencies to detect, investigate, and mitigate fraudulent or abusive activities
• Ensure compliance with federal and state healthcare regulations
• Lead design, implementation, and ongoing optimization of pre-payment review process
• Oversee daily volume of claims and monitor program effectiveness through savings, cost avoidance, provider behavior changes, and regulatory compliance metrics
• Utilize claims data analysis, predictive analytics, and fraud detection tools to identify suspicious patterns and activities
• Manage and develop a team of professional certified coders and investigative analysts

• Bachelor’s Degree
• 10 years law enforcement/investigation experience or healthcare fraud investigation experience
• 3 years management experience, including supervision of investigators and/or professional certified coders
• Organizational skills, results oriented with demonstrated leadership skills
• Experience in the implementation of pre-payment review process
• Exceptional analytical, problem-solving, and decision-making abilities
• Strong executive communication and presentation skills
• PC proficiency to include the MS Office Suite (Word, Excel, PowerPoint, Teams) as well as Workday
• Preferred:
  Certified Professional Coder (CPC) designation
• Preferred:
  Experience with WRIKE (SaaS work management process platform)

Demonstrates expertise in managing healthcare fraud investigations, leading teams of certified coders and analysts, and ensuring compliance with healthcare regulations. Proficient in utilizing data analysis and fraud detection tools to optimize pre-payment review processes and mitigate fraudulent activities.