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

Qualifications

Required:

• Bachelor degree or equivalent education and relevant job experience in lieu of a degree
• Five (5)+ years of regulatory or compliance experience
• One (1) to three (3) years' experience in health plan operations and/or management
• Proven leadership skills and prior management experience
  • Ability to lead others to achieve desired results, including (but not limited to):
  • Ability to assess individual performance and communicate assessments effectively
  • Ability to identify and effectively and efficiently resolve employee performance issues
  • Ability to establish goals and assist others to achieve goals and meet expectations
  • Ability to lead others to improve work processes
• Good working knowledge of regulatory requirements/standards
• Superior written and oral communications
• Excellent quantitative and analytic skills
• Ability to build and maintain relationships internally and externally - across business units, and with State and Federal regulatory agencies
• Strong leadership and interpersonal skills
• Ability to lead and manage in a cross-functional environment
• Ability to manager multiple work streams, projects, tasks and goals
• Ability to conduct compliance monitoring and audit reviews
• Knowledge of claims coding, regulatory rules, medical policy & terminology
• Knowledge of different claims payment methodologies and claim editing guidelines
• Experience working with Medicare/Medicaid/Commercial managed care claims
• Demonstrated ability to effectively prioritize and execute tasks in a high-pressure environment and meet contractual timelines
• Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook)

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status