Special Investigation Unit Manager
$90,000–$100,000 year
HybridSunrise, Florida, United States
Job Summary
Lead the Special Investigations Unit by overseeing Medicaid Program Integrity efforts, including fraud detection, case investigation, and overpayment recoveries. Conduct comprehensive interviews with providers and witnesses, analyze data to identify aberrant billing patterns, and perform data-mining activities to uncover new cases. Manage case documentation, coordinate with subcontractors and law enforcement, and prepare investigative reports for regulatory agencies and audit findings. Establish and maintain relationships with AHCA-Medicaid Program Integrity and facilitate compliance with state and federal FWA requirements. This role requires a bachelor's degree, 5–7 years of healthcare program integrity experience, and nationally recognized anti-fraud certification. Candidates must be proficient in Microsoft Excel, possess strong analytical skills, and be able to travel 1–3 days per occurrence for quarterly meetings.
Required Qualifications
- Bachelor's degree
- 5–7 years of experience in a healthcare program integrity role ensuring compliance with regulatory and contractual requirements
- Expertise in healthcare fraud and abuse prevention, detection, and investigative processes, with the ability to design, implement, and oversee a fraud and abuse program
- Knowledge of healthcare fraud, waste, and abuse (FWA) methodologies, investigative approaches, and applicable regulations
- Healthcare industry and/or Medicaid/CHIP knowledge
- Ability to travel, as business needs require, for quarterly Medicaid Program Integrity (MPI) meetings and other organizational meetings
- Travel is typically one (1) to three (3) consecutive days per occurrence
- Must hold a nationally recognized anti-fraud certification, such as Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE)
- Or the ability to achieve a nationally recognized anti-fraud certification within 1 year/12 months of employment
- Must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse
Desired Qualifications
- Healthcare claims knowledge and experience
- Medical terminology knowledge and/or experience with CPT and ICD-10 coding
- Proficiency with Microsoft Office applications, including advanced Microsoft Excel
- Knowledge of current FWA trends, emerging schemes, and issues of interest to law enforcement and regulatory agencies
- Ability to work independently with minimal supervision while managing a high volume of assignments
- High degree of integrity and ability to maintain confidentiality when handling sensitive and protected information
- Strong analytical, deductive reasoning, and problem-solving skills with the ability to think logically and sequentially
- Strong verbal and written communication skills
- Knowledge of internal and external resources used to support fraud investigations
- Ability to communicate effectively, verbal and written
- Ability to self-motivate
- Strong time management skills
- Ability to prioritize and organize FWA program activities
- Ability to meticulously document case actions and findings for regulatory reporting and any legal action, if applicable
- Ability to collaborate
- Results oriented skills
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