Special Investigations Unit (SIU) Director - Remote

📋 Description

• • Lead and strategically direct Martin’s Point Health Care’s (MPHC) comprehensive Fraud, Waste, and Abuse (FWA) program as the Director of the Special Investigations Unit (SIU).
• • Oversee the planning, organization, and execution of all SIU activities, ensuring alignment with organizational goals and regulatory requirements.
• • Manage and mentor the Audit & Recovery team, fostering a high-performance culture focused on accuracy, efficiency, and integrity in all investigations and audits.
• • Develop and implement robust investigative strategies to identify, assess, and address instances of fraud, waste, and abuse within the healthcare system.
• • Provide expert oversight and guidance on risk adjustment activities, ensuring compliance and mitigating associated risks.
• • Interpret complex audit findings and translate them into actionable insights and strategic recommendations for health plan executives.
• • Drive the development and implementation of effective action plans to address identified issues, including leading financial recovery efforts where applicable.
• • Diligently monitor, evaluate, and manage third-party vendors engaged in audit and recovery activities, ensuring performance meets or exceeds contractual and regulatory standards.
• • Identify opportunities for process improvement, technological advancements, and the implementation of best practices within the SIU to enhance operational effectiveness.
• • Ensure strict adherence to all federal and state regulations pertaining to fraud, waste, and abuse, including timely and accurate reporting obligations.
• • Collaborate closely with the Legal department to manage and respond to all legal inquiries, including subpoenas and court appearances, ensuring a coordinated and legally sound approach.
• • Represent MPHC at key federal (CMS and/or DHA) and state fraud meetings, industry events, and training sessions, staying abreast of emerging trends and regulatory changes.
• • Prepare and present comprehensive reports on SIU activities, findings, and recommendations to business teams, the Executive Management Team, and the Board of Directors, providing clear and concise updates on program performance.
• • Actively participate in and leverage FWA/SIU industry associations, coalitions, and stakeholder groups to support and enhance MPHC’s program and industry best practices.
• • Cultivate and maintain strong, collaborative relationships with federal and state regulators, investigatory units, and enforcement agencies, fostering trust and open communication.
• • Champion and contribute to a culture of compliance, corporate citizenship, and diversity, equity, inclusion, and belonging throughout the organization.
• • Drive continuous learning and professional development within the SIU team, ensuring staff possess the necessary expertise and skills to address evolving FWA challenges.
• • Proactively identify potential areas of risk and develop preventative strategies to minimize exposure to fraud, waste, and abuse.
• • Ensure all audit and investigation documentation is meticulously maintained and compliant with applicable guidelines.
• • Serve as a key point of contact for internal stakeholders seeking expertise on FWA matters, providing guidance and support across various departments.
• • Contribute to the strategic direction of MPHC’s compliance and risk management framework.
• • Uphold the company's values of taking care of ourselves and others, continuous learning, helping each other, and having fun in all aspects of leadership and team management.
• • Foster an environment of trust and respect, aligning with Martin's Point's mission to transform healthcare and create a healthier community.
• • Ensure the SIU operates with the highest ethical standards and integrity, reflecting the organization's commitment to being a "Great Place to Work."