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WVUH Specialty Pharmacy & Home Infusion · 2 months ago

Special Investigations Unit (SIU) Program Manager

United States

Full-time

Remote

Mid Level

4+ years exp

WVUH Specialty Pharmacy & Home Infusion is seeking a Special Investigations Unit (SIU) Program Manager to develop and manage a program for preventing and investigating fraud, waste, and abuse in healthcare. This role involves collaborating with various departments and managing the SIU program and vendors to support payment integrity.

Hospital & Health Care

Responsibilities

Develop, maintain, and execute annual audit program

Ownership of the SIU referral intake and triage process. Ensuring all referrals are investigated and followed up on as appropriate

Perform investigations into suspected fraud, waste, and abuse, including all necessary planning, fieldwork, and reporting activities

Leads process and reporting to ensure proper and timely notification of FWA activity to appropriate law enforcement and/or regulatory agency

Identify opportunities for improvement through the audit process and provide recommendations for enhancement

Creation and maintenance of departmental policies and procedures, educational materials, etc

Works collaboratively with other departments to educate providers and vendors

Lead and participate in meetings and workgroups with internal and external parties

Track, report, and follow-up on overpayments and recoveries

Participate in audit and regulatory reviews by providing documentation, summaries, and subject matter expertise related to SIU operations

Collaborate with Compliance, Legal, Claims, and accounting departments to coordinate investigative activities, share findings, and support appropriate corrective or disciplinary actions

Serve as a subject matter expert and internal resource on issues related to FWA prevention and detection

Maintain current knowledge of healthcare fraud trends, enforcement priorities, and best practices in SIU program management

Partner with the Compliance department to ensure SIU activities align with applicable federal and state laws, including CMS, Medicaid, and commercial payer requirements

Manage relationships with external vendors, consultants, and technology partners to ensure service quality, performance, and contract compliance

Qualification

Payment integrity experienceCertified Fraud Examiner (CFE)Medicare/MedicaidMedical chart reviewAccredited Health Care Fraud Investigator (AHFI)Certified Professional Coder (CPC)Fraud/data mining toolsMicrosoft Office expertiseCommunication skills