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Director of Special Investigations Unit

Job Ref: 46134
Category: Professional
Location: New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $110,000.00
Salary Range: $110,000.00 - $140,000.00

Marketing Statement

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

The Director of the Special Investigations Unit (SIU) will oversee the plan’s responsibility under federal and New York State laws, regulations and policies for the detection, prevention and investigation of suspected fraud, waste and abuse.   The position reports directly to the Chief Operating Officer with a dotted line for daily operations to the Senior Director of Network Relations. 

Job Description

  • Develop SIU strategic direction and create and monitor the annual FWA work plan.
  • Investigating allegations of fraud, waste and abuse from internal and external sources including cases brought by the NYS Office of Medicaid Inspector General, District Attorneys’ offices, Medicaid Fraud Control Unit, CMS and other sources  
  • Managing and monitoring work and performance of the SIU services vendor including review of provider claims data analyses, case lead generation, recoupment tracking, fraud schemes and investigations and regulatory reporting 
  • Liaising with MetroPlus Claims Department and pharmacy, dental, radiology, DME and other vendors to investigate allegations of fraud, waste or abuse
  • Overseeing preparation of investigative reports and recommendations based on data analyses and investigations for presentation to the Fraud Waste and Abuse Committee
  • Responding to information requests made by the OMIG, DA, MFCU, CMS, FBI, etc. regarding fraud waste and abuse
  • Developing, reviewing, and updating SIU policies and procedures to meet ensures SIU compliance with all state and federal requirements
  • Working with Corporate Compliance to ensure timely submission of regulatory and internal reporting, and fulfillment of subpoenas and Requests for Information.
  • Collaborate with Corporate Compliance and business areas to assist in implementation of overpayment recoveries and corrective action for deficiencies identified through investigations, monitoring and auditing activity.
  • Direct SIU staff in managing workload, assigning tasks, monitoring progress against annual FWA work plans and meeting regulatory timelines, bringing forth issues to Legal and Corporate Compliance, as necessary. 
  • Act as SIU subject matter expert for court testimony, affidavits, and with regulators.
  • Maintain an understanding of current state and federal insurance statutes, regulations, and internal policies to ensure compliance. 
  • Participate in the development and delivery of FWA training for MetroPlus employees as well as any required training for first tier and downstream entities.
  • Support the initiatives of the Corporate Compliance Department, leveraging cross functional subject matter expertise to improve the overall effectiveness of the MetroPlus Compliance Program.

Minimum Qualifications

  • Bachelor’s degree in an appropriate discipline and at least one year of related work experience in either compliance, claims or investigator role in managed care
  • Minimum of 8 years of fraud investigation experience within a managed care plan or health care organization
  • Preferred candidate will/be possess/be:
    • Master’s Degree
    • And/or attorney with SIU experience and expertise.

Licensure and/or Certification

  • Certified Fraud Examiner designation

  • And/or attorney with SIU experience and expertise.

Professional Competencies

  • Broad-based in-depth knowledge of the managed care industry, including: strategic compliance planning, regulatory concerns, compliance requirements, and corporate integrity principles. The ability to comprehend and interpret regulatory, legislative, and contractual mandates
  • Experience with managed care, Medicare and federal and/or state regulations, quality improvement and compliance oversight
  • High-level of skill in leading interdepartmental and cross-functional strategy development; experience managing professional staff on multiple projects to ensure corporate deadlines and objectives are met. Simultaneously manage multiple projects
  • Excellent oral, written, and presentation skills, as well as conceptual and analytic skills are necessary in order to review and articulate corporate objectives and Federal regulations across all relevant audiences
  • The utmost integrity in the discreet and confidential handling of confidential materials is necessary
  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication

How To Apply

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:

MetroPlus Health Plan
Human Resources Department
160 Water Street 8th Floor
New York, NY 10038
Attn: Recruitment Unit

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