The Manager of Special Investigations Unit (SIU) and Coordination of Benefits (COB) is responsible for the oversight of the Special Investigations Unit (SIU) which combines the responsibilities and activities of provider audit, fraud waste and abuse (FWA) and program integrity. In addition, this position is also responsible for the management of the coordination of benefits team and initiatives that will ensure a sound payment integrity structure and successful execution of all cost containment and recovery objectives related to third party and COB.
Duties and Responsibilities
Responsibilities include, but are not limited to, the following:
- Management of SIU staff ensuring compliance with established policies and procedures. Ensures that SIU staff log and thoroughly document all provider audit and FWA complaints, incidents and leads
- Provides coordination to all SIU team members on recommendations and further actions and/or resolution to support investigative needs
- Management of Coordination of Benefits staff to ensure timely and accurate complete of Coordination of Benefits (COB) and Third-Party Liability (TPL) review
- Provide oversight of vendor invoicing including validation, reconciliations and adjustments to support invoice approvals
- Provide coordination to all SIU team members on recommendations and further actions and/or resolution to support investigative needs
- Create partnerships with other departments to create and maintain process flows for provider audit, FWA and COB/TPL functions
- Manage and organize meetings with providers, employees, business partners and where appropriate, representatives from regulatory agencies
- Maintain effective lines of communication with Director of Payment Integrity, Compliance Officer and Compliance Committee and provides regular updates on all FWA and Payment Integrity issues with escalation, as needed
- Review and assist SIU staff in preparation of assessments and audits, case summaries and detailed reports, as needed
- Develop and maintain contacts/ liaison with law enforcement, regulatory agencies, task force members, other SIU staff, and other external contacts involved in fraud investigation, detection and prevention
- Engage in on-going performance management of staff including coaching, mentoring, development, training and succession planning to include hiring and termination decisions
- Manage all outbound reporting activities and ensures regulatory and other timelines are met
- Manage the implementation of new payment integrity solutions related to Third Party Liability and Coordination of Benefits
- Other duties as assigned
- Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents