Director, Special Investigations Unit

Company: Medica Health Management LLC
Location: Minnetonka
Posted on: May 20, 2025

Job Description:

The Special Investigations Unit (SIU) is responsible for preventing, detecting, investigating and correcting potential fraud and abuse by providers, enrollees and others. The director will identify opportunities to strengthen the efficiency and effectiveness of SIU's program integrity and serve as the liaison for Medica's legal team and external authorities. Responsibilities include but are not limited to: program development and management that applies industry expertise and strategic direction in healthcare Fraud, Waste and Abuse (FWA); managing investigative and administrative staff; providing direction and oversight of investigations and regulatory reporting/contacts; data mining analysis; auditing/monitoring activities; and mandatory regulatory reporting.Key Accountabilities:Program Development & Management

• Responsible for the strategic direction of SIU and leveraging the FWA risk assessments to create and monitor the annual FWA work plan.
• Oversee activities of the SIU, including investigations of referrals or leads of potential Fraud and Abuse and required documentation of investigations.
• Responsible to ensure SIU remains compliant with all state and federal requirements, including, but not limited to policies and procedures, regulatory and operational reporting, fulfillment of subpoenas and Requests for Information (RFIs).
• Lead and ensure that the SIU is meeting its regulatory and contractual requirements under federal and state law, including mandatory reporting requirements.
• Develop and implement ongoing monitoring strategies to detect fraud and abuse to assure the integrity of payment for services and to identify patterns and trends of potential Fraud and Abuse. Ensure monitoring activities include prepayment and post payment data analytics to identify potential and actual cases of Fraud and Abuse.
• Oversee investigative case management, in order to achieve department goals and complete unit initiatives.
• Develop and implement Fraud and Abuse training programs and materials to educate internal staff and external stakeholders.
• Coordinate with delegates and contracted vendors in the investigation of suspected FWA. Participate in delegate and vendor contract reviews and negotiations as requested.
• Oversee drafting and filing of annual Fraud and Abuse Plan with the Minnesota Department of Human Services (DHS) to ensure compliance with contract requirements.
• As necessary or requested, periodically meet with state or federal regulators to discuss FWA activities and trends.
• Ensure SIU team cooperates fully with applicable investigations by a state or federal regulator and in any subsequent legal actions.
• Proactively collaborate with law enforcement and regulatory agencies to share FWA trends and new patterns of activity to monitor; develop relationships with others in the health care community for shared learning and coordination around FWA
• Coaches and develops direct reports.
• Promotes and models appropriate communication skills and continuous improvement principles relative to team department and organizational issues.
• Communicates accurate and timely information to team members to maximize compliance and performance. Develop key performance indicators as are necessary.
• Coordinates training and development opportunities for team members.
• Direct SIU staff in managing workload, assigning tasks, monitoring progress against annual FWA work plans and meeting regulatory timelines, bringing forth issues to Legal, and the Vice President, Compliance.
• Develop, maintain, and enhance collaborative relationships with the AG's office, FBI, DOH, DHS, OIG, local law enforcement and other external agencies to address abuse and fraud issues affecting Medica members and providers as well as the entire community.
• Information exchange coordination for sharing of information with law enforcement (HIPAA).
• Serve as the primary contact for all external law enforcement and regulatory cases, as the point person to receive all requests for information and participate in the external case task forces when needed. Participate in depositions/interviews as is necessary.
• Prepare and submit required FWA reporting to regulatory agencies, the Compliance Oversight Committee and the Audit Committee of the Medica Board of Directors.Qualifications:
  • Bachelors degree in criminal justice, business management, health services or related field, or equivalent work experience required plus 10 years of working experience with at least 5 years of management experience required.
  • Experience analyzing health care claims data. Experience using health care fraud analytics software such as Healthcare Fraud Shield. Experience with database programming language such as SQL , OBI, or Python for data buildouts related to FWA investigations. Knowledge of project management and/or process improvement methodologies.
  • Established working relationship with law enforcement agencies is preferred.
  • The desired candidate will have experience in criminal/civil insurance investigation and have a working knowledge of provider contracts, member certificates of coverage and claims processing procedures.Skills and Abilities:
    • Demonstrated experience and skills in public speaking.
    • Excellent written and verbal communication skills.
    • Conflict management and negotiation skills are also important.
    • Experience testifying in criminal and/or civil litigation cases.This position is an Office role, which requires an employee to work from the designated office, Minnetonka MN or Madison WI, on average, 3+ times per week.The full salary range for this position is $111,200 - $190,600. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.QualificationsSkillsBehaviors:Motivations:EducationExperienceLicenses & CertificationsEqual Opportunity Employer/Protected Veterans/Individuals with Disabilities
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Keywords: Medica Health Management LLC, Lakeville , Director, Special Investigations Unit, Executive , Minnetonka, Minnesota