Special Investigations Unit Manager PCHP

PRIMARY PURPOSE

Responsible for managing the operations of the Special Investigations Unit (SIU). Accountable for the investigation, detection, reporting, referral, and mitigation of provider, member, prescriber, and other suspected fraud, waste, and abuse (FWA). Ensures SIU activities comply with applicable Texas Medicaid and CHIP contractual requirements, HHSC Office of Inspector General (OIG), Medicaid Fraud Control Unit (MFCU), state and federal requirements, and organizational policies.

MINIMUM SPECIFICATIONS

Education

• Bachelor's Degree.
• Preferred: Bachelor's degree in Healthcare Administration, Business Administration, Criminal Justice, Legal Studies, Accounting, Finance, Health Information Management, or related discipline. Master's degree in Healthcare Administration, 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: 2 years of supervisory or people leadership experience preferred. Texas Medicaid and CHIP managed care experience strongly preferred. Experience working with regulatory agencies such as HHSC-OIG, MFCU, CMS, or other healthcare regulatory or law-enforcement agencies preferred.

Certification/Registration/Licensure

• None.

Required Test for Placement

• None.

Skills or Special Abilities

• Strong knowledge of healthcare investigative techniques, healthcare claims, billing and coding, medical terminology, reimbursement methodologies, and healthcare delivery systems|High|Required.
• Strong knowledge of Texas Medicaid and CHIP managed care FWA requirements and applicable state and federal healthcare regulations. |High|Required.
• Knowledge of healthcare FWA schemes, data analytics, data mining, provider profiling, sampling methodologies, and case development. |High|Required.
• Ability to analyze claims, utilization, provider, and financial information to identify potential FWA. |High|Required.
• Ability to interpret regulatory requirements and translate them into operational processes, policies, and controls. |Medium|Required.
• Must have strong written and verbal communication, interpersonal, organizational, analytical, and time-management skills. |High|Required.
• Ability to manage multiple investigations, regulatory deadlines, and competing priorities.|High|Required.
• Ability to maintain confidentiality and appropriately safeguard sensitive investigative information.|High|Required.
• Must be proficient with Microsoft Office. |Medium|Required.
  

Responsibilities

• Manages the day-to-day operations of the Special Investigations Unit and provides oversight of FWA investigations.
• Oversees investigations involving suspected provider, member, prescriber, subcontractor, and other healthcare fraud, waste, and abuse.
• Ensures investigations are completed within applicable regulatory, contractual, and organizational timeframes.
• Monitors case inventory, case aging, investigator workload, investigative milestones, and regulatory deadlines.
• Develops and oversees proactive and reactive processes for identifying potential fraud, waste, and abuse.
• Leads the development, implementation, maintenance, and periodic review of the organization's FWA Plan and related SIU policies and procedures.
• Establishes, monitors, and reports SIU performance measures, including case inventory and aging, regulatory timeliness, investigator workload and productivity, investigation quality, investigative outcomes, regulatory referrals, identified overpayments, recoveries, and corrective actions.
• Recruits, develops, coaches, and manages qualified SIU staff.
• Adheres to organizational policies, procedures, ethical standards, and applicable legal and regulatory requirements.
• Maintains confidentiality of investigative, member, provider, employee, and organizational information.•    Ensures compliance with applicable Texas Medicaid and CHIP SIU/FWA regulatory and contractual requirements.
• Oversees timely and accurate preparation and submission of required SIU/FWA regulatory reports.
• Ensures suspected FWA matters are appropriately evaluated and referred to HHSC-OIG, MFCU, law enforcement, or other regulatory entities as required.
• Ensures regulatory referrals contain complete and accurate investigative findings and supporting documentation.
• Coordinates responses to regulatory inquiries, audits, investigations, and requests for information.
• Monitors changes to applicable state and federal FWA requirements and ensures SIU processes are updated as necessary.
• Maintains SIU readiness for regulatory audits and reviews.
              

Job Accountabilities

• Identifies and analyzes the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of PCHP.
• 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.
• 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.
• 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.
• Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of PCHP.
• 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.