LOCATION: Remote - must live in or near Vaya's catchment area. Incumbent in this role must live in North Carolina or within 40 miles of the NC border.

GENERAL STATEMENT OF JOB

The Special Investigations Director works under the direct supervision of the Vice President (VP) of Compliance. The Special Investigations Director will lead the Special Investigations Unit in the prevention, identification and investigation of healthcare fraud, waste and abuse (FWA) within the Vaya Health Provider Network. This position requires extensive oral and written communication with Vaya Network Providers, with state and federal regulatory agencies, and licensing entities. This position requires oversight of the application of cutting-edge analytics tools, and robust processes to confront the ever-changing challenges of detecting and resolving FWA. This position requires a high, consistent and frequent degree of team involvement to ensure efficiency, consistency, seamlessness and optimum performance.

ESSENTIAL JOB FUNCTIONS

Operations Management:

• Oversee the Special Investigations Unit activity
• Oversee the Investigation Oversight Committee (IOC) Triage process
• Represent the Special Investigations Unit on appointed committees as directed by the VP of Compliance and/or Chief Compliance Officer (CCO)
• Serve as the contact for the Division of Health Benefits OCPI and Medicaid Investigations Division referrals and inquiries
• Identify and report provider trends that are indicators of potential fraud, waste or abuse to the IOC
• Receive oral and written direction, monitoring and guidance from the VP of Compliance and CCO
• Develop and monitor an annual SIU work plan and ensure elements of the plan are completed in a timely and accurate manner
• Update the Fraud Prevention Plan and SIU policies and procedures as required to ensure compliance with all applicable federal and state laws, rules and regulations, accreditation standards and payor program requirements including, but not limited to, the North Carolina State Plan for Medical Assistance, the North Carolina combined 1915 (b)/(c) Medicaid Waiver, the North Carolina 1115 Medicaid Reform Demonstration Waiver, and Vaya's contracts with the North Carolina Department of Health and Human Services Interpret applicable federal or state laws, rules and regulations, accreditation standards and payor program requirements, including, but not limited to, the Waiver for investigation oversight activities
• Oversee the development and delivery of educational awareness and training on compliance and standards of conduct, to include responsibility for reporting, for the organization and providers
• Interact and coordinate investigation activities with governmental law enforcement and regulatory agencies
• Develop, initiate, and monitor return on investment project to determine financial effectiveness of SIU monitoring and investigation activities
• Provide investigative assistance and testimony for healthcare cases being investigated by DHB appeals and other LME-MCOs across the State as needed
• Report provider review findings to internal and external entities as requested and applicable
• Assist in making referrals to the Division of Health Benefits OCPI
• Participate in both informal and formal appeal processes, defending SIU decisions before hearing officers and administrative law judges

Supervisory:

• Directly supervise the Special Investigations Operations Manager and Clinical Investigators
• Provide oversight of the investigations assigned to the Clinical Investigators
• Provide ongoing staff development and support in accomplishment of departmental responsibilities
• Respond to staff inquiries and oversee staff training activities
• Develop and monitor direct supervisees individual performance indicators
• Oversee team performance indicators
• Complete performance evaluations for direct supervisees
• Approve supervisee staff timesheets, leave requests and travel and training requests

Other duties as assigned.

KNOWLEDGE, SKILL & ABILITIES

• Knowledge of healthcare service definitions, service documentation, and service utilization requirements
• Knowledge of Local, State and Federal laws and regulations pertaining to insurance and/or healthcare services
• Knowledge of medical coding, ICD-10, HCPCS, HIPAA, etc.
• Knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions
• Excellent decision-making abilities to determine the appropriate course of action concerning SIU investigations and subsequent follow-up
• Ability to prepare detailed and comprehensive reports, to present facts clearly, and to instruct others in the development of reports
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud Medicaid and Non-Medicaid programs
• Ability to provide effective consultation, education and training to others
• Ability to establish and maintain positive and effective working relationship with others
• Ability to work autonomously, exercising sound judgement and problem resolution skills

QUALIFICATIONS & EDUCATION REQUIREMENTS

Master's degree in Human Services or related field required. Must have:

• 2 years supervisory experience and experience coordinating projects across multiple departments highly preferred.

Licensure/Certification Required:

• North Carolina licensure, which includes HSP-PA, LCSW, LPA, LMFT, LCMHC, PhD or PsyD.
• Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified Professional Coder preferred but not required.
• Employee must maintain credentials including requirements for licensure (e.g. CEUs).

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.
• Mental concentration is required in all aspects of work.

RESIDENCY REQUIREMENT: This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.