Special Investigation Unit Investigator Lead

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

Under the direction of the Privacy Officer, the Special Investigations Unit (SIU) Investigator Lead, is responsible for providing leadership and supporting the prevention, detection, investigation, reporting and when appropriate, recovery of money related to health care fraud, waste and abuse.

Amount of Travel Required: 10%

Work Schedule: Occasional travel to multiple sites and different locations. Flexibility to work beyond normal business hours as needed.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.  The incumbent performs a variety of administrative duties that require a degree of analytical, organizational, and technical skills and exercises a level of discretion and judgment appropriate for the scope of the position. 

Major Duties and Responsibilities:

•    Assist with the development and maintenance of a Special Investigations Unit.

•    Attend and present at the Compliance Committee and any other required Committee.  Direct and create memos, presentations and applicable charts/graphs for committee presentation.

•    Perform end-to-end investigations, including but not limited to witness interviews, data analytics, contract and program regulation research, provider and member education, recommendations of outcomes and closure of investigations.

•    Complete investigations within the mandated period required by either State and/or Federal contracts and regulations.

•    Review and analyze information to draw conclusions on allegations of FWA.

•    Produce and submit audit reports for internal and external review.

•    Develop new queries and reports to detect potential fraud, waste and abuse.

•    Provide updates on progress of investigations and coordinate with departments on recommendations and further actions and/or resolutions.

•    Prepare summary and/or detailed reports or investigative findings for referral to Federal and State agencies. 

•    Maintain accurate recordkeeping of all investigative notes, findings and outcomes.

•    Coordinate and work with various internal stakeholders.

•    Prepare and ensure all investigative documentation is prepared timely and accurately.

•    Interact with regulatory and/or law enforcement agencies where needed.

•    Assist with staff development and training.

•    Monitor progress and ensure completeness of investigations and findings.

•    Communicate results of investigations and any issues or outliers to the Privacy Officer.

•    Analyze, update and modify procedures and processes to continually improve SIU operations; provide recommendations to the Privacy Officer.

•    Stay informed about the latest developments in FWA and SIU operations, including new regulations, products, services and alerts from the DOJ and CMS.

•    Ability to analyze and interpret legal and contractual language.

•    Ability to define issues, interpret data and evaluate options.

•    Ability to establish and maintain effective and cooperate working relationships with GCHP staff and others contacted in the course of the work.

•    Ability to create forms and letters, compile reports and various information as required.

•    Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.

•    Ability to effectively prioritize multiple tasks and deadlines.

•    Ability to effectively, clearly and independently document, summarize and resolve complex issues.

•    Ability to accurately complete tasks within established times.

•    Other related duties as assigned.

POSITION QUALIFICATIONS 

Competency Statements

•    Technical Aptitude - Ability to comprehend complex technical topics and specialized information.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

•    Customer Oriented - Ability to take care of the customers’ needs while following company procedures.

•    Communication, Oral - Ability to communicate effectively with others using the spoken word.

•    Communication, Written - Ability to communicate in writing clearly and concisely.

•    Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

•    Analytical Skills – Ability to use thinking and reasoning to solve a problem

SKILLS & ABILITIES

Education:                           

•    High School Graduate or General Education Degree (GED): Required

•    Bachelor's Degree, Field of Study: Criminal Justice or equivalent

•    Experience in lieu of degree accepted

Minimum Qualifications:                      

•    Minimum 2 years of experience in Medicare Fraud, Waste and Abuse

•    5 plus years of experience in healthcare fraud and investigations

Preferred Qualifications:

•    Experience in managed care environment

•    Master’s Degree Preferred, Field of Study: Criminal Justice, Healthcare Administration or equivalent

•    Computer Skills: Demonstrated proficiency included in the MS Office products, Outlook, Teams, Word, Excel, Access, Power BI and PowerPoint

Other Requirements:     

•    Demonstrates effective general writing skills and business report writing skills.

•    Ability to establish, nurture and maintain strong and effective working relationships with the GCHP staff.

•    Ability to maintain detailed and accurate records, follow oral and written directions, prepare written agendas, and transcribe minutes

•    Ability to work independently with minimal supervision or within a team environment.

•    Ability to utilize conflict resolution and problem-solving techniques

•    Ability to operate a keyboard and sit for long periods. 

•    Ability to read close-up and do close-up work. 

•    Ability to perform repetitive motion (keyboard); writing (notetaking). 

•    Ability to hear normal speech, hear and talk on telephone.

•    Ability to think and work effectively under pressure. 

•    Ability to deal with public contact.

•    Decision making, concentration.