Special Investigations Director (Remote NC)

LOCATION: Remote - This is a home based, virtual position that operates Monday - Friday from 8:30am-5:00pm EST. Applicants must live in North Carolina or within 40 miles of the NC border.GENERAL STATEMENT OF JOBThe Special Investigations Director works under the direct supervision of the Vice President (VP) of Compliance. The Special Investigations Director will lead the Special Investigations Unit in the prevention, identification and investigation of healthcare fraud, waste and abuse (FWA) within the Vaya Health Provider Network. This position requires extensive oral and written communication with Vaya Network Providers, with state and federal regulatory agencies, and licensing entities. This position requires oversight of the application of cutting-edge analytics tools, and robust processes to confront the ever-changing challenges of detecting and resolving FWA. This position requires a high, consistent and frequent degree of team involvement to ensure efficiency, consistency, seamlessness and optimum performance.ESSENTIAL JOB FUNCTIONSOperations Management:Oversee the Special Investigations Unit activityOversee the Investigation Oversight Committee (IOC) Triage processRepresent the Special Investigations Unit on appointed committees as directed by the VP of Compliance and/or Chief Compliance Officer (CCO)Serve as the contact for the Division of Health Benefits OCPI and Medicaid Investigations Division referrals and inquiriesIdentify and report provider trends that are indicators of potential fraud, waste or abuse to the IOCReceive oral and written direction, monitoring and guidance from the VP of Compliance and CCODevelop and monitor an annual SIU work plan and ensure elements of the plan are completed in a timely and accurate mannerUpdate the Fraud Prevention Plan and SIU policies and procedures as required to ensure compliance with all applicable federal and state laws, rules and regulations, accreditation standards and payor program requirements including, but not limited to, the North Carolina State Plan for Medical Assistance, the North Carolina combined 1915 (b)/(c) Medicaid Waiver, the North Carolina 1115 Medicaid Reform Demonstration Waiver, and Vaya's contracts with the North Carolina Department of Health and Human Services Interpret applicable federal or state laws, rules and regulations, accreditation standards and payor program requirements, including, but not limited to, the Waiver for investigation oversight activitiesOversee the development and delivery of educational awareness and training on compliance and standards of conduct, to include responsibility for reporting, for the organization and providersInteract and coordinate investigation activities with governmental law enforcement and regulatory agenciesDevelop, initiate, and monitor return on investment project to determine financial effectiveness of SIU monitoring and investigation activitiesProvide investigative assistance and testimony for healthcare cases being investigated by DHB appeals and other LME-MCOs across the State as neededReport provider review findings to internal and external entities as requested and applicableAssist in making referrals to the Division of Health Benefits OCPIParticipate in both informal and formal appeal processes, defending SIU decisions before hearing officers and administrative law judgesSupervisory:Directly supervise the Special Investigations Operations Manager and Clinical InvestigatorsProvide oversight of the investigations assigned to the Clinical InvestigatorsProvide ongoing staff development and support in accomplishment of departmental responsibilitiesRespond to staff inquiries and oversee staff training activitiesDevelop and monitor direct supervisees individual performance indicatorsOversee team performance indicatorsComplete performance evaluations for direct superviseesApprove supervisee staff timesheets, leave requests and travel and training requestsOther duties as assigned.KNOWLEDGE, SKILLS, & ABILITIESKnowledge of healthcare service definitions, service documentation, and service utilization requirementsKnowledge of Local, State and Federal laws and regulations pertaining to insurance and/or healthcare servicesKnowledge of medical coding, ICD-10, HCPCS, HIPAA, etc.Knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutionsExcellent decision-making abilities to determine the appropriate course of action concerning SIU investigations and subsequent follow-upAbility to prepare detailed and comprehensive reports, to present facts clearly, and to instruct others in the development of reports Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud Medicaid and Non-Medicaid programsAbility to provide effective consultation, education and training to othersAbility to establish and maintain positive and effective working relationship with othersAbility to work autonomously, exercising sound judgement and problem resolution skillsQUALIFICATIONS & EDUCATION REQUIREMENTSMaster's degree in Human Services, business, or related field required. Must have:5 years of progressive professional experience involving healthcare or insurance related matters2 years supervisory experience and experience coordinating projects across multiple departments highly preferred.Preferred licensure/certification:Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified Professional Coder preferred but not required.North Carolina licensure, which includes HSP-PA, LCSW, LPA, LMFT, LCMHC, PhD or PsyD. (Employee must maintain credentials including requirements for licensure (e.g. CEUs).)PHYSICAL REQUIREMENTSClose visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. Mental concentration is required in all aspects of work.RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation. DEADLINE FOR APPLICATION: Open Until FilledAPPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.Vaya Health is an equal opportunity employer. Apply tot his job Apply To this Job