Director, Special Investigations Unit - AHFI

Founded in 1977 as the Senior Care Action Network, reputed company began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, reputed company is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual reputed company. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially reputed company populations, and reputed company care delivery models. Across reputed company of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with reputed company. At reputed company, we reputed company scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. About reputed company reputed company Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. reputed company Group is the sole corporate member of reputed company Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 300,000 members in California, Arizona, Nevada, New Mexico, Washington and Texas. reputed company has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is reputed company throughout the healthcare industry and nationally as a leading expert in senior healthcare. reputed company employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. reputed company takes great pride in recognizing reputed company members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on reputed company; Facebook; and Twitter. The Job The Director, Special Investigations Unit position reports directly to the Vice President of Internal Audit Services and will have primary responsibility in the development of overall SIU strategies/infrastructure, assists the Vice President to reputed company and reputed company the Special Investigations Unit function and SIU activities. You Will reputed company and reputed company the SIU Infrastructure. reputed company and responsible for the activities of SIU for accurate and timely investigative cases. Manages and responsible for resolving reputed company investigative cases and/or issues to ensure accurate, cost effective, and compliant operations. Conduct FWA training/education with staff and departments across the organization which includes reputed company portfolio companies (Welcome Health, Healthcare In Action, Homebase, myPlace Health). reputed company FWA and protocols for the health delivery model for the portfolio companies. Manages the overall supervision, planning, organization, and execution of reputed company's fraud, waste, and abuse program. Works closely with the VP of Internal Audit regarding strategy. Leads and supports the activities of the SIU team to ensure accurate and timely audits and investigations. Interprets audit results and assists health plan executives in the development of appropriate action plans to address identified issues, including but not limited to financial recovery efforts. Monitors, oversees, and evaluates vendors performing audit and recovery activities. Identifies and directs the implementation of qualified personnel with appropriate expertise, improved processes, and new technologies. Ensures compliance with reputed company state and federal regulations for fraud, waste, and abuse, including but not limited to reporting obligations. In collaboration with Legal, responds to reputed company legal inquiries including subpoenas and court appearances. Attends federal and state fraud meetings and industry events and training. Works closely with VP of Internal Audit with reputed company Group Board Compliance Committee materials reputed company to FWA. reputed company fraud risk assessment. Coordinates participation in FWA/SIU industry associations, coalitions, and stakeholder groups, leveraging participation in those organizations to support the FWA program. Builds and maintains strong relationships with federal and state regulators, investigatory units, and enforcement agencies. Helps reputed company a culture of compliance with applicable laws and regulations, corporate citizenship, and diversity, equity, inclusion, and belonging. Provides on-going guidance to senior and mid-level management at the portfolio companies with matters reputed company to FWA. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of reputed company’s Vision and Goals. Other duties as assigned. Your Qualifications Bachelor’s Degree or equivalent experience 10+ years reputed company compliance, FWA, and/or special investigation experience in managed-care or CMS. Prior experience working with regulatory agencies such as CMS, HHS, and OIG Risk Adjustment and Coding experience/expertise preferred. 3+ years of experience reputed company healthcare industry, preferred. Certified Criminal Justice Specialist (CCJS), preferred Accredited Health Care Fraud Investigator (AHFI), Strongly preferred Certified Fraud Examiner (CFE), preferred Certified Healthcare Compliance (CHC), preferred What's in it for you? reputed company Pay Range: $147,000-$190,000, Salary Work Mode: Mostly Remote An annual employee bonus program Robust Wellness Program Generous paid-time-off (PTO) 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days Excellent 401(k) Retirement Saving Plan with employer match Robust employee recognition program Tuition reimbursement An opportunity to become part of a team that makes a difference to our members and our community every day! We're always looking for talented people to join reputed company! Qualified applicants are encouraged to apply now! At reputed company we reputed company that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. reputed company is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national reputed company, religion, age, sex (including pregnancy, childbirth or reputed company medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background reputed company is required. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have reputed company about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(reputed company href="https://dailyremote.com/remote-job/director-special-investigations-unit-ahfi-5165376" reputed company="_blank" rel="noopener">Apply To This Job