It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.
Reporting to the Senior Manager, Special Investigations Unit, the Supervisor of the Special Investigations Unit is responsible for management and oversight of the Special Investigations Unit. The SIU Supervisor trains staff, assigns work, and resolves complex issues to ensure accurate, cost effective and compliant operations. This position is responsible for reviewing and approving work product for all levels of investigators, both clinical and non-clinical, as well as the SIU Data Analyst and the SIU Coordinator. The SIU Supervisor will also determine outcomes of SIU referrals during triage, as well as providing guidance to all investigators related to their investigative case plans. This individual also works closely with the SIU Operations Manager to monitor staff and departmental productivity and efficiency, making adjustments in workflows/staff assignments as needed. Additionally, the SIU Supervisor supports the Senior Manager in day-to-day operations and focused initiatives. This individual may function as the liaison between clinical suppliers and the SIU as it relates to the Special Investigations Unit.
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Our Investment in You:- Full-time remote work
- Competitive salaries
- Excellent benefits
Key Functions/Responsibilities:
- Work with Manager on the SIU department strategy
- Provides direct accountability for SIU case inventory management
- Monitors and evaluates the quality, timeliness and accuracy of team processes
- Ensures that all SIU recoveries are processed accurately and in a timely manner in Facets in compliance with the MCO contracts
- Coordinates with SIU team and gathers documentation related to requests from federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters
- Ensures that investigations progress with minimal delays, as well as provides guidance to meet State expectations as well as possible State incentives based on timeliness of investigations and referrals
- Maintains current, in-depth knowledge of all WellSense benefits, payment policies, provider network, configuration issues, Medicaid and Medicare billing practices
- Responsible for maintaining accurate and consistent updated SIU policies, processes and procedures and related training manuals in conjunction with the SIU Operations Manager
- Responsible for staff hiring, work allocation and scheduling, training and professional development, performance management and related supervisory activities
- Responsible for leading triage meetings, as well as determining outcomes of each lead
- Review all requests to open investigations, fraud referrals, corrective action plans and provider letters to ensure quality, accuracy, and clarity before submission to States for approval
- Provide guidance to all investigators related to investigative case plans
- Managing SIU work queues in facets, as well as ensuring SIU appeals are resolved timely
- Review SIU Coordinator and SIU Data Analyst work product, and provide guidance as needed
- Collaborates with other department supervisors in the planning, development and coordination of department specific and cross-functional initiatives
- Facilitates team meetings as well as clinical supplier meetings, and may lead and represent the SIU in various state FWA related regulatory meetings
- Works with the SIU Operations manager to creates FWA trainings for internal Health Plan staff as well as for vendors delegated to investigate FWA on behalf of the Plan
- Identifies, communicates, and escalates issues on a timely basis
- Independently problem solves programmatic issues and implements appropriate solutions
- Develops and oversees the production of standard KPI reports to monitor and report on overall department metrics and inventory management
- Other duties as assigned
- Supervises 8-10 FTEs
Qualifications:
Education Required:
- Bachelor’s degree in Health Information Management, Health Care Administration, Nursing or Other Clinical Field, Public Health, Criminal Justice, Law Enforcement or other related field; an equivalent combination of education, training, and experience may be considered
Education Preferred:
- Advanced degree in an above noted area
Experience Required:
- Minimum of six years of experience in a health care payer setting
- Minimum of six years of experience in a health care fraud control setting (e.g., Special Investigations/Program Integrity Unit, Recovery Audit Contractor, Medicaid Fraud Control Unit)
- Experience in a leadership role or equivalent training, mentoring and directing others
- Experience developing job aides, training manuals
- Three or more years’ experience utilizing coding certification
Experience Preferred/Desirable:
- Six years of experience in the Managed Care industry preferred; five years’ experience in Medicaid Managed Care highly preferred
- Five years of experience in a Medicaid or Medicaid Managed Care fraud detection unit
- Experience developing and monitoring performance metrics
- Working knowledge of regulatory requirements in an FWA related healthcare environment preferred
- Four or more years’ experience utilizing coding certification
- Two or more years’ experience with Facets claim processing
Required Licensure, Certification or Conditions of Employment:
- Health care coding certification (CPC or CCS) required
- National Health Care Anti-Fraud Association certification (AHFI), Certified Fraud Examiner (CFE), or America’s Health Insurance Plans Health Care Anti-Fraud Associate (HCAFA) designation, earned within first year of hire
Competencies, Skills, and Attributes:
- Proactive, motivated, and a collaborative team player
- Strong critical thinking, analytical, and problem-solving skills including the ability to determine root causes and to define workable solutions
- Ability to analyze, compile, format, and present data to a variety of stakeholders
- Demonstrated ability to manage competing priorities as well as stakeholders with differing objectives/perspectives
- Demonstrated ability to work independently and manage multiple complex projects simultaneously
- Effective at forming alliances with other departments to develop partnerships and commitment toward completing the project
- Ability to interact with all levels of the organization, as well as external stakeholders
- Superior meeting facilitation skills and experience in leading teams
- Effective process improvement skills
- Excellent verbal and written communication skills with the ability to clearly articulate thoughts, ideas, processes and requirements to both internal and external audiences and in potentially contentious situations
- Excellent organizational skills and attention to detail
- Excellent proof reading and editing skills
- Customer service skills with the ability to interact professionally and effectively with a wide variety of providers, third party payers, staff from all departments within and outside the Plan, law enforcement, and regulatory partners
- Advanced level skills in developing investigative strategies
- Demonstrated intermediate proficiency with Microsoft Office products, including but not limited to Word, and Excel, including Excel pivot tables
- Time management skills necessary to meet established deadlines in a fast-paced environment, including the ability to re-prioritize tasks as workload and time constraints dictate
- Proven ability to maintain objectivity and the utmost confidentiality
About WellSense
WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances.
- WellSense will require proof of COVID-19 vaccination(s) as a term of employment for all employees. The company may make exceptions to this requirement in certain limited circumstances for religious or medical purposes.
Required Skills
Required Experience
