Special Investigations Unit Manager
CareOregon, Madison, WI, United States
Working Conditions
Work Environment(s): Indoor/Office
This position manages and administers fraud, waste and abuse (FWA) for CareOregon and two wholly‑owned Coordinated Care Organizations (CCOs) – Columbia Pacific CCO (CPCCO) and Jackson Care Connect CCO (JCC CCO). This includes leading, overseeing and/or performing fraud investigations and providing regular FWA reporting to all CareOregon CCOs. Additionally, this position manages internal staff and provides FWA oversight for Third‑Party Administrative (TPA) activities CareOregon performs on behalf of the Health Share CCO.
Compensation
Estimated Hiring Range: $111,690.00 - $136,510.00
Bonus Target: SIP Target, 5% Annual
Note: Benefits and eligibility information is described in the Benefits section.
Essential Responsibilities
Fraud, Waste and Abuse Management
Manage the development and operation of an effective fraud, waste, and abuse program in accordance with CMS requirements and the Federal Sentencing Guidelines with guidance from department leadership, including:
Recommendation and implementation of FWA policies and the FWA annual plan
Periodic reporting to the organization’s Internal Compliance Committee and governing Board of Directors
Effective training and education
Establishment and maintenance of effective lines of communication at all levels of the organization (to include a non‑compliance reporting hotline)
Development and oversight of an effective system for routine FWA monitoring, auditing and identification of compliance risks
Collaboration with other departments to ensure compliance issues are reported to appropriate channels for investigation and resolution
Clear and specific policies, procedures and standards relating to compliance monitoring activities
Ensure the timely completion of the annual FWA work plan and evaluate the corresponding work performed by department staff
Perform and manage FWA investigations conducted by CareOregon staff, affiliates, and business partners
Complete and file all required Medicare and Medicaid filings and/or responses for FWA
Manage the development of sufficient and accurate monthly FWA dashboards and corresponding summaries used to identify and monitor current compliance and trending of all FWA matters including case details and metrics
Identify potential areas of FWA vulnerability and risk; partner with department leadership in developing and implementing corrective action plans for resolution of problematic issues and provide general guidance on how to avoid or deal with similar situations in the future
Provide input into strategic planning and budget planning for the department
Employee Supervision
Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values
Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens
Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations
Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff
Train, supervise, motivate, and coach employees; provide support toward employee development
Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making
Ensure team adheres to department and organizational standards, policies, and procedures
Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action)
Perform supervisory tasks in collaboration with Human Resources as needed
Required Experience and Education
As required by our Medicaid contract, the individual must be a professional investigator, paralegal, professional coder, or auditor with corresponding certification
Minimum 5 years’ experience in compliance and/or audit, including minimum 2 years focused on fraud, waste, and abuse
Preferred
Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program
Fraud, waste and abuse experience in Medicaid or Medicare
Knowledge, Skills and Abilities
Knowledge
Advanced understanding of healthcare fraud, waste and abuse
Strong knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid Programs
Strong knowledge of investigative techniques, including interviews, data analytics, evidence gathering, case documentation
Solid understanding of information and reporting systems
Knowledge about how the functions of a business work and relate to one another to benefit the member by improving regulatory compliance
Skills and Abilities
Excellent written and verbal communication skills
Strong research, investigative and problem-solving skills
Strong interpersonal and motivational skills
People leadership skills, including the ability to manage and coach team members
Ability to facilitate learning opportunities in a variety of informal and formal settings
Ability to make presentations to small and large groups
Ability to think logically and creatively without undue influence from personal biases
Ability to build conceptual models and communicate complex ideas effectively
Ability to plan, organize, manage, and monitor work projects
Ability to serve in an internal consulting role, assisting the organization’s management and staff in embracing our goal of “doing it right the first time” and being cognizant of the company’s commitments to its various partners and the need to achieve excellent results in our work product and processes
Ability to work effectively with diverse individuals and groups
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day
Working Conditions
Work Environment(s): Indoor/Office
Member/Patient Facing: No
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
Benefits
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre‑tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility.
Equal Opportunity
CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.
#J-18808-Ljbffr
Work Environment(s): Indoor/Office
This position manages and administers fraud, waste and abuse (FWA) for CareOregon and two wholly‑owned Coordinated Care Organizations (CCOs) – Columbia Pacific CCO (CPCCO) and Jackson Care Connect CCO (JCC CCO). This includes leading, overseeing and/or performing fraud investigations and providing regular FWA reporting to all CareOregon CCOs. Additionally, this position manages internal staff and provides FWA oversight for Third‑Party Administrative (TPA) activities CareOregon performs on behalf of the Health Share CCO.
Compensation
Estimated Hiring Range: $111,690.00 - $136,510.00
Bonus Target: SIP Target, 5% Annual
Note: Benefits and eligibility information is described in the Benefits section.
Essential Responsibilities
Fraud, Waste and Abuse Management
Manage the development and operation of an effective fraud, waste, and abuse program in accordance with CMS requirements and the Federal Sentencing Guidelines with guidance from department leadership, including:
Recommendation and implementation of FWA policies and the FWA annual plan
Periodic reporting to the organization’s Internal Compliance Committee and governing Board of Directors
Effective training and education
Establishment and maintenance of effective lines of communication at all levels of the organization (to include a non‑compliance reporting hotline)
Development and oversight of an effective system for routine FWA monitoring, auditing and identification of compliance risks
Collaboration with other departments to ensure compliance issues are reported to appropriate channels for investigation and resolution
Clear and specific policies, procedures and standards relating to compliance monitoring activities
Ensure the timely completion of the annual FWA work plan and evaluate the corresponding work performed by department staff
Perform and manage FWA investigations conducted by CareOregon staff, affiliates, and business partners
Complete and file all required Medicare and Medicaid filings and/or responses for FWA
Manage the development of sufficient and accurate monthly FWA dashboards and corresponding summaries used to identify and monitor current compliance and trending of all FWA matters including case details and metrics
Identify potential areas of FWA vulnerability and risk; partner with department leadership in developing and implementing corrective action plans for resolution of problematic issues and provide general guidance on how to avoid or deal with similar situations in the future
Provide input into strategic planning and budget planning for the department
Employee Supervision
Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values
Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens
Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations
Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff
Train, supervise, motivate, and coach employees; provide support toward employee development
Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making
Ensure team adheres to department and organizational standards, policies, and procedures
Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action)
Perform supervisory tasks in collaboration with Human Resources as needed
Required Experience and Education
As required by our Medicaid contract, the individual must be a professional investigator, paralegal, professional coder, or auditor with corresponding certification
Minimum 5 years’ experience in compliance and/or audit, including minimum 2 years focused on fraud, waste, and abuse
Preferred
Minimum 2 years’ experience in a supervisory position or minimum 1 year experience in a supervisory position with completion of CareOregon’s Aspiring Leaders Program
Fraud, waste and abuse experience in Medicaid or Medicare
Knowledge, Skills and Abilities
Knowledge
Advanced understanding of healthcare fraud, waste and abuse
Strong knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid Programs
Strong knowledge of investigative techniques, including interviews, data analytics, evidence gathering, case documentation
Solid understanding of information and reporting systems
Knowledge about how the functions of a business work and relate to one another to benefit the member by improving regulatory compliance
Skills and Abilities
Excellent written and verbal communication skills
Strong research, investigative and problem-solving skills
Strong interpersonal and motivational skills
People leadership skills, including the ability to manage and coach team members
Ability to facilitate learning opportunities in a variety of informal and formal settings
Ability to make presentations to small and large groups
Ability to think logically and creatively without undue influence from personal biases
Ability to build conceptual models and communicate complex ideas effectively
Ability to plan, organize, manage, and monitor work projects
Ability to serve in an internal consulting role, assisting the organization’s management and staff in embracing our goal of “doing it right the first time” and being cognizant of the company’s commitments to its various partners and the need to achieve excellent results in our work product and processes
Ability to work effectively with diverse individuals and groups
Ability to learn, focus, understand, and evaluate information and determine appropriate actions
Ability to accept direction and feedback, as well as tolerate and manage stress
Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
Ability to hear and speak clearly for at least 3-6 hours/day
Working Conditions
Work Environment(s): Indoor/Office
Member/Patient Facing: No
Hazards: May include, but not limited to, physical and ergonomic hazards.
Equipment: General office equipment
Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.
Work Location: Work from home
Benefits
We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre‑tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility.
Equal Opportunity
CareOregon is an equal opportunity employer. The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.
#J-18808-Ljbffr