Special Investigations Unit Director jobs in Virginia Beach, VA

Sentara Health is seeking to hire a qualified individual to join our team as a Director, Special Investigation Unit (SIU)

Position Status: Full-time, Day Shift

Position Location: Sentara Park in Virginia Beach, VA

Standard Working Hours: 8:00AM to 5:00PM (ET).

Position Summary:

The Special Investigations Unit (SIU) Director oversees all commercial and government medical claims related fraud, waste, and abuse activities.

Responsibilities:

• Develops and implements a strategic plan for the identification, investigation, recovery, and prevention of fraud against the Health Plan.
•  Minimize risk of loss due to fraudulent and/or abusive actions by providers, members, vendors, contractors, and associates through an effective fraud and abuse detection program.
• Institutes and maintains an effective communication program on the importance of risk mitigation, effective internal controls, fraud prevention and detection for management and associates.
• Ensure that all regulatory and compliance reports pursuant to state and federal are accurately submitted within specified time.
• Identifies, engages, maintains, and oversees related third-party contracts.
• Establishes and ensures the maintenance of strong State and Federal regulatory agency (FWA specific) relationships.
• Ensures adherence to nationally recognized FWA unit performance and execution standards.
• Ensures the establishment and maintenance of effective, cross-functional, working relationships within the Company (e.g., Claims, Appeals & Grievances, Legal, Network Management, etc).
• Ensure FWA management and staff have a sound working knowledge of the Company claims processing organization, functional alignment, and duties and responsibilities.
• Develop, initiate, maintain, and revise policies and procedures for the general operation of the SIU.
• Responsible for identifying, recruiting, interviewing, hiring, and deploying staff to optimize performance. Conduct performance reviews of assigned staff and provide constructive feedback, coaching and take disciplinary action as necessary.
• Provides reports on a regular basis and as directed or requested to keep senior management informed of the operation and progress of fraud prevention and detection efforts.
• Develops and ensures compliance with State and Federal regulations relative to healthcare fraud, waste & abuse.
• Provides compliance advice and assists with organizational change and compliance interpretation as it relates to fraud, waste and abuse.

Minimum Requirements:

• Education:
  • Bachelor’s Level Degree Required
• Certification/License:
  • Accredited Health Care Fraud Investigator (AHFI) Required
• Experience:
  • Five (5) years Leadership/Supervisory experience
  • Eight (8) years Healthcare fraud investigations experience including:
    • Coding
    • Internal/External Audit
    • Regulatory Compliance

Diversity and Inclusion at Sentara

Our vision is that everyone brings the strengths that come with diversity to work with them every day. When we are achieving our vision, we have team members that feel they belong and can be their authentic selves, and our workforce is reflective of the communities we serve.

We are realizing this vision through our Diversity and Inclusion strategy, which has three pillars: A diverse and talented workforce, an inclusive and supportive workplace, and outreach and engagement with our community. We have made remarkable strides in these areas over the past several years and, as our world continues to evolve, we know our work is never done.

Our strategies focus on both structural inclusion, which looks at our organizational structures, processes, and practices; as well as behavioral inclusion, which evaluates our mindsets, skillsets, and relationships. Together, these strategies are moving our organization forward in an environment that fosters a culture of mutual respect and belonging for all.

Please visit the link below to learn more about Sentara’s commitment to diversity and inclusion:

Sentara's Commitment to Diversity & Inclusion

Sentara Overview
For more than a decade, Modern Healthcare magazine has ranked Sentara Health as one of the nation's top integrated healthcare systems.  That's because we are dedicated to growth, innovation, and patient safety at more than 300 sites of care in Virginia and northeastern North Carolina, including 12 acute care hospitals.

Sentara Benefits
As the third-largest employer in Virginia, Sentara Health was named by Forbes Magazine as one of America's best large employers.  We offer a variety of amenities to our employees, including, but not limited to: 

• Medical, Dental, and Vision Insurance
• Paid Annual Leave, Sick Leave
• Flexible Spending Accounts
• Retirement funds with matching contribution
• Supplemental insurance policies, including legal, Life Insurance and AD&D among others
• Work Perks program including discounted movie and theme park tickets among other great deals
• Opportunities for further advancement within our organization

Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace.  For information about our employee benefits, please visit: Benefits - Sentara (sentaracareers.com)

Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development, and growth!

Please Note: The yearly Flu Vaccination is required for employment.

Note: Sentara Health offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

Remote Candidates must have residency in one of the following states: Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington State, West Virginia, Wyoming

• Accredited Health Care Fraud Investigator (AHFI) - Certification - National Health Care Anti-Fraud Association (NHCAA)

• Bachelor's Level Degree

• Leadership 5 years
• Coding 8 years
• Internal/External Audit 8 years
• Regulatory/Compliance 8 years
• Healthcare Fraud and Abuse 8 years

• Leadership
• Judgment and Decision Making
• Critical Thinking
• Coordination
• Complex Problem Solving
• Communication
• Active Listening
• Active Learning
• Writing
• Troubleshooting
• Time Management
• Technology/Computer
• Systems Evaluation
• Systems Analysis
• Speaking
• Social Perceptiveness
• Service Orientation
• Science
• Reading Comprehension
• Quality Control Analysis
• Project Management
• Persuasion
• Monitoring
• Microsoft Word
• Microsoft Excel
• Mgmt of Staff Resources
• Mgmt of Material Resources
• Mgmt of Financial Resources
• Mathematics
• Learning Strategies