Director of Special Investigations in New York, NY

  • Title: Director of Special Investigations
  • Code: RCI-11923
  • RequirementID: 105066
  • Location: New York, NY 10004
  • Posted Date: 01/18/2023
  • Duration:
  • Salary ($): 0.00 - 0.00 per Yearly
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  Job Description

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.  

Scope of Role & Responsibilities

  • 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 Client 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 Client 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 Client Compliance Program.

Required Education, Training & Professional Experience:

  • 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

About Rangam:

Rangam Consultants is a minority, women-owned, disability workforce solutions global organization. Specialized in attracting and retaining talents globally for a rewarding career in IT, Engineering, Scientific, Clinical, Healthcare, Administrative, Finance, Business Management, and many more, while integrating veterans and individuals with disabilities into the workforce. Indeed, we connect career aspirants to relevant job opportunities, be it jobs in USA, UK, India, or Ireland. Also remote jobs, work-from-home jobs, or contract jobs in different verticals and industries.
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