Director, Special Investigations
Company: Brigham and Women's Hospital
Posted on: September 16, 2023
Job Description - Director, Special Investigations (3255117)
Director, Special Investigations - ( 3255117 ) Mass General Brigham
Health Plan is an exciting place to be within the healthcare
industry. As a member of Mass General Brigham, we are on the
forefront of transformation with one of the world's leading
integrated healthcare systems. Together, we are providing our
members with innovative solutions centered on their health needs to
expand access to seamless and affordable care and coverage.Our work
centers on creating an exceptional member experience - a commitment
that starts with our employees. Working with some of the most
accomplished professionals in healthcare today, our employees have
opportunities to learn and contribute expertise within a
consciously inclusive environment where diversity is celebrated. We
are pleased to offer competitive salaries, and a benefits package
with flexible work options, career growth opportunities, and much
more. -The Director, Special Investigations Unit (SIU) will report
to Sr. Vice President, Legal, Regulatory Affairs and Compliance and
is responsible for supporting the prevention, detection,
investigation, reporting, and when appropriate, recovery of money
related to health care fraud, waste, and abuse. The SIU team will
perform accurate and reliable medical review audits, analyze
medical billing and codes, conduct confidential investigations
related to compliance and regulatory requirements, documenting the
investigation through audit reports for interview and external
review which document the findings, and reporting issues of
non-compliance in accordance with all laws and regulations. In
addition, this position will review claims, look for patterns of
potential fraud, waste and/or abuse and interact with medical
providers to request medical records for investigations.The
Director, Special Investigations Unit (SIU) is responsible for
management and oversight of the Special Investigations Unit. The
Director, SIU trains staff, assigns work, and resolves complex
issues to ensure accurate, cost effective and compliant operations.
This position is responsible for reviewing and approving work
product for all levels of investigators, both clinical and
non-clinical. The Director, SIU will also determine outcomes of SIU
referrals during triage, as well as provide guidance to all
investigators related to their investigative case plans. This
position also monitors staff and departmental productivity and
efficiency, while adjusting workflows/staff assignments as needed.
Additionally, the Director, SIU supports the day-to-day operations
and focused initiatives. This individual may function as the
liaison between clinical suppliers and the SIU as it relates to the
Special Investigations Unit.Principal Duties and Responsibilities:
--- Provides oversight and review of the SIU referral intake and
investigation process while giving guidance and direction to team
on case investigation steps and actions.
--- Works with leadership to maintain and revise policies and
procedures, fraud, waste, and abuse plans, annual audit work plans,
including department guidance memos, and educational materials.
--- Identifies opportunities for improvement through the audit
process and provide recommendations for system enhancement to
augment investigative outcomes and performance.
--- Accurately tracks, reports, and follows up on overpayments and
--- Leads business requirement process and reporting to ensure
proper and timely notification of case activity to the appropriate
regulatory and/or law enforcement agency.
--- Provides direct accountability for SIU case inventory
--- Monitors and evaluates the quality, timeliness, and accuracy of
--- Ensures that all SIU recoveries are processed accurately and in
a timely manner in compliance with the MCO contracts.
--- Coordinates with SIU team and gathers documentation related to
requests from federal, state, and local law enforcement agencies in
the investigation and prosecution of healthcare fraud and abuse
--- Ensures that investigations progress with minimal delays, as
well as provides guidance to meet State expectations as well as
possible State incentives based on timeliness of investigations and
--- Maintains current, in-depth knowledge of all Mass General
Brigham Health Plan benefits, payment policies, provider network,
configuration issues, Medicaid, and Medicare billing practices.
--- Responsible for maintaining accurate and consistent updated SIU
policies, processes and procedures and related training
--- Responsible for staff hiring, work allocation and scheduling,
training and professional development, performance management and
related supervisory activities.
--- Responsible for leading triage meetings, as well as determining
outcomes of each lead.
--- Review all requests to open investigations, fraud referrals,
corrective action plans and provider letters to ensure quality,
accuracy, and clarity before submission to States for approval.
--- Provide guidance to all investigators related to investigative
--- Managing SIU work queues, as well as ensuring SIU appeals are
--- Collaborates with other department supervisors in the planning,
development, and coordination of department specific and
--- Facilitates team meetings as well as clinical supplier meetings
and may lead and represent the SIU in various state FWA related
--- Identifies, communicates, and escalates issues on a timely
--- Independently problem solves programmatic issues and implements
--- Develops and oversees the production of standard KPI reports to
monitor and report on overall department metrics and inventory
--- Hold self and others accountable to meet commitments.
--- Ensure diversity, equity, and inclusion are integrated as a
--- Persist in accomplishing objectives to consistently achieve
results despite any obstacles and setbacks that arise.
--- Build strong relationships and infrastructures that designate
Mass General Brigham Health Plan as a people-first
--- Other duties as assigned with or without accommodation.
Qualifications: ---- Bachelor's degree required or the equivalent
combination of training and experience, plus 5-7 years of related
--- Minimum of 6 years' experience in a health care payer setting
and/or in a health care fraud control setting
--- Health care coding certification (CPC or CCS) required.
--- Accredited Healthcare Fraud Investigator (AHFI) certification
or Certified Fraud Examiner (CFE) required.
--- Master's degree preferred.
--- 5-6 years' experience in the Managed Care industry, Medicaid or
Medicaid Managed care fraud detection unit
preferred.Skills/Abilities/Competencies: ---- Demonstrate Mass
General Brigham Health Plans core brand principles of always
listening, challenging conventions, and providing value. -
--- Bring fresh ideas forward by listening to and working with
employees and the people we serve. -
--- Respect the talent and unique contributions of every individual
and treat all people in a fair and equitable manner.
--- Strong, demonstrated track record of an ability to execute on
time, on budget, and on scope. -
--- Strong aptitude for technology-based solutions. -
--- Ability to inject energy, when and where it's needed.
--- Current in healthcare trends.
--- Demonstrated forward, visionary thinking; ability to see "what
is" and envision "what could be."
--- Ability to develop, introduce, defend, and gain support for a
new ideas and approaches. -
--- Excellent leadership skills and leadership track record.
--- Ability to translate and communicate complex topics in a
variety of forums, tailoring communications to effectively fit and
influence the targeted audience, strong executive presence,
presentation, and communication skills. Strong verbal, active
listening, and written communication skills required.
--- Ability to view the long-range trends and cycles of the
business and industry and see the "big picture." -
--- Ability to apply a variety of strategic frameworks to analyze
problems and to guide and develop solutions.
--- Ability to challenge the status quo and drive innovative
thinking and the capability to successfully implement strategy.
--- Excellent interpersonal skills, including the ability to
influence others at all levels of an organization.
--- Strong EQ; exercises self-awareness; monitors impact on others;
is receptive to and seeks out feedback; uses self-discipline to
adjust to feedback.
--- Unquestionable integrity.
- Mass General Brigham is an Equal Opportunity Employer. By
embracing diverse skills, perspectives and ideas, we choose to
lead. All qualified applicants will receive consideration for
employment without regard to race, color, religious creed, national
origin, sex, age, gender identity, disability, sexual orientation,
military service, genetic information, and/or other status
protected under law. We will ensure that all individuals with a
disability are provided a reasonable accommodation to participate
in the job application or interview process, to perform essential
job functions, and to receive other benefits and privileges of
employment. - Primary Location MA-Somerville-MGB Health Plan at
Assembly Row Work Locations MGB Health Plan at Assembly Row Job
Organization Mass General Brigham Health Plan Schedule Full-time
Standard Hours 40 Shift Day Job Employee Status Regular Recruiting
Department MGB Health Plan Regulatory Affairs
Keywords: Brigham and Women's Hospital, Somerville , Director, Special Investigations, Accounting, Auditing , Somerville, Massachusetts
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