What are the responsibilities and job description for the Special Investigation Unit Mgr., El Paso Health position at University Medical Center of El Paso?
Job Summary
Assists the Compliance Director in maintaining compliance with the Special Investigations Unit (SIU) requirements enforced by the HHSC Uniform Managed Care Contract, Texas Department of Insurance (TACs/TICs), Office of Inspector General, and Office of Attorney General. Responsible for conducting investigations related to Member and Provider waste, abuse, and fraud (WAF) in El Paso Health’s Medicaid and CHIP programs and educating Providers on appropriate billing guidelines. Oversees all cases, whether conducted in-house or through a contracted SIU. Responsible for the supervision of the SIU Clerk, SIU Claims Auditor and SIU Registered Nurse.
Skills
1. The ability to identify, prevent, and mitigate healthcare fraud, waste and abuse.
2. The ability to direct fraud detection and investigation activities as well as developing strategies to minimize fraud risks, ensuring compliance with regulatory standards.
3. Ability to follow department and state guidelines in conformity with policies and procedures.
4. Excellent verbal and written communication skills.
5. Proficiency in Microsoft Software.
6. Self-starter with the ability to work independently and take initiative.
7. Ability to meet deadlines while producing quality analyses.
8. Highly organized and detailed orientated.
9. Working knowledge of auditing concepts and statistical analysis methods.
10. Ability to analyze and solve problems.
11. Strong presentation skills.
Work Experience
Three years of supervisory or management experience required. Working knowledge in coding regulations, and billing practices including but not limited to National Correct Coding Initiative (NCCI) guidelines, ICD-10 (International Classification of Diseases, 10th Edition), CPT (Current Procedural Terminology), HCPCS (Healthcare Common Procedure Coding System) preferred. An understanding of fraud and abuse rules, along with working knowledge of Medicare and Medicaid rules preferred.
License/Registration/Certification
Certified Fraud Examiner (CFE) through the Association of Certified Fraud Examiners (ACFE) or Accredited Health Care Fraud Investigator (AHFI) through the National Health Care Anti- Fraud Association (NHCAA) required to be obtained within two years of being in the position.
Education and Training
Bachelor degree in Healthcare or Business related field is required.
