Director, SIU / Fraud Waste and Abuse - REMOTE

Knowledge/Skills/Abilities

Acts as liaison between Special Investigations Unit (SIU) operations and contracted vendor(s) to assure a smooth workflow exists, quality assurance measures are designed and monitored, appropriate handoffs to functional teams are adhered to, and the appropriate approvals and escalations are achieved. Coordinates with both the Associate Vice President of Fraud, Waste and Abuse (FWA) and Associate Vice President of Special Investigations Unit (SIU) to oversee the special investigations unit vendor outlier analytics and case management system, training and implementation. Serves as a backup for the AVP of SIU in maintaining an effective payment integrity program for all lines of business by promoting ethical practices and a commitment to compliance with applicable federal, state, and local laws, rules, regulations and internal policies and procedures related to detecting, correcting, and preventing fraud, waste and abuse. Responsibilities may include data mining and data analysis, developing audit tools based on regulatory and contractual requirements, summarizing and approving investigations, resolving escalated disputes from providers, members, or related entities, documenting and/or conducting investigations of potential FWA or overpayment allegations, assisting in responding to external audits, maintaining a schedule of active corrective action plans and follow-up activities. Drives efforts to identify and resolve overpayments and to detect, correct, and prevent FWA incidents in an overall payment integrity framework.

Essential Duties & Responsibilities

• Creates and manages effective monitoring metrics to continually evaluate vendor contract requirements are met including quality, cost control, timeliness and business relations

• Assures an adequate quality assurance program and process are in place and strictly adhered to for all tasks

• Ensures that all turn-around-times and quality measurements are met

• Identifies improvement opportunities in protocols, and creates projects to address opportunity from root cause analysis through implementation

• Oversees vendor FWA case management including tracking on schemes, coordinating internal efforts with vendor to avoid duplication of efforts, assuring case statuses and disputes are appropriately resolved, assures timeliness of resolution, and assures referral compliance adherence

• Performs reviews of case files for sufficiency of content and documentation, approves and signs-off where appropriate

• Implements the most effective and efficient method of investigation for each FWA case and administers outcomes with vendor

• Tracks on budgeted recoveries, and initiates appropriate action plans to assure program stays on track

• Provides guidance to operational managers on the implementation and completion of resulting action plans

• Directs training for SIU unit personnel on internal and external protocols and systems and investigative techniques

• Oversees data mining and data analysis to identify outliers/potential fraud, waste, abuse and overpayments within overall payment integrity framework

• Strategizes with cross functional teams on payment integrity program advancements and best practice development

• Responsible to engage staff and drive high level of change management and business process transformation

• Represents the payment integrity area at key stakeholder internal and external meetings

• Capitalizes on opportunities to create pre-payment edits for recurring overpayment instances with cross functional teams, and drives cost avoidance measures

• Develops and maintains payment integrity policy and procedures, and ensures that all activities conform to the policy and procedures

• Evaluates the work of personnel and completes all required performance review documentation as applicable

• Performs special projects as requested by Leadership

• Attends professional conferences as assigned to ensure ongoing knowledge of regulatory guidance

• Maintains professional and technical knowledge through appropriate activities and ongoing learning

• Other duties as identified and assigned.

Job Qualifications

Required Education

• Bachelor's degree in a job related field

Required Experience

• Minimum of 8-10 years relevant experience in special investigation units, Insurance Fraud and Abuse, Payment Integrity Program, Law Enforcement or Risk Management

• Minimum 8-10 years leadership/supervisory experience required

• Progressive management experience to manage complex work systems and workflows required

• Knowledge of pre-edit and pre and post payment audit protocol, and payment integrity program protocols

• Excellent oral and written communication skills

• Strong organizational and leadership skills

• Strong independent decision making and critical thinking skills

• Strong negotiation, and conflict management skills

• Ability to succeed in a fast paced environment with evolving workflow and changing priorities

• Proficiency in Microsoft Access, Word and Excel

• Knowledge and understanding of claims processing systems and medical claims

• Knowledge of HMO, PPO, POS, MCO, Medicare, Medicaid, Market Place products, laws, rules and regulations

Preferred Education

• Master's degree

Preferred Experience

• Formalized training/experience in Health Care Insurance Fraud

• Experience with Power BI, SAS, SQL other reporting software

• ICD-10 CPT-4, HCPCS coding

Preferred License, Certification, Association

Professional certifications/accreditations, such as CFE, AHFI, HCAFA

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $97,299 - $227,679 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.