We are seeking a Manager, Special Investigations Unit to join our client, prominent nonprofit health care company contracting in Medicaid plans within the state of Indiana. This position is full-time, and mostly remote except for visits to the office in Indianapolis, Indiana for training and meetings. Therefore, the Manager, Special Investigations Unit must live in the Indianapolis area or be willing to relocate.

The Manager, Special Investigations Unit is responsible for overseeing the activities of the Special Investigative Unit and serves as a subject matter expert in Medicaid program integrity. This position plays a critical role in detecting and preventing fraud, waste, and abuse within Indiana Medicaid and other company lines of business while collaborating closely with both the legal and compliance departments.

Resumes may be submitted directly or via email to hr@roisg.com.

Responsibilities:

• Lead and supervise Special Investigative Unit (SIU) analysts and auditors in efforts to detect and prevent fraud, waste, and abuse within the Indiana Medicaid program.
• Manage caseloads effectively, ensuring that cases are documented accurately and reported in compliance with Scope of Work Program Integrity requirements.
• Conduct prepayment reviews for high-risk providers, ensuring they meet established performance metrics.
• Oversee the Beneficiary Verification Program, verifying services rendered through monthly letters to members. Analyze provider utilization patterns within company claims data to identify potential fraud, waste, and abuse.
• Conduct audits of providers’ financial transactions, claims submissions, and medical records, including coding audits, clinical audits, and pre-payment review audits.
• Provide ongoing training to SIU staff regarding industry best practices and relevant topics.
• Assist in creating and maintaining policies and procedures for fraud and abuse prevention and detection.
• Participate in cross-functional committees to streamline processes aimed at preventing fraud, waste, and abuse, including regular Compliance Committee meetings.
• Meet with the Office of Medicaid Policy and Planning Program Integrity Unit (OMPP PI) quarterly or as directed.
• Review investigation and audit findings with Legal to determine appropriate next steps, including provider education and referrals to relevant agencies.
• Prepare and present detailed Audit Finding Reports that include findings, provider education, and briefings for state agencies, and provide testimony in legal proceedings as required.
• Establish and maintain relationships with relevant industry, regulatory, and law enforcement agencies.
• Perform other duties as assigned to ensure the efficient operation of the department and the company.

Experience:

Required:

• Bachelor’s degree preferred. Experience in lieu of a degree will be considered.
• Three (3) years of experience in fraud, waste, and abuse audits and/or investigations; internal audits and/or investigations; and/or criminal audits and/or investigations, with direct, related complex progressive experience
• Two (2) years of experience in a management role with direct reports leading or assisting in all phases of effective supervision (i.e.. Recruitment, performance management, training).
• Candidate must be approved by the Indiana Medicaid agency prior to hiring and the agency may ask to interview candidate.

 Preferred:

• Two years of experience and knowledge of HMO, PPO, TPA, PHO and managed care functions (e.g., marketing, administration, medical delivery, regulatory compliance, claims processing, membership/eligibility, contracting and risk arrangements.
• Certification as a Certified Fraud Examiner (CFE), Certified Professional Medical Auditor or Accredited Healthcare Fraud Investigator

Benefits:

Our client offers a variety of benefits for their team members. Team members can choice from two health, three dental, and vision insurance plans that best fit their needs. In addition, the organization offers a retirement plan with generous matching. Recognizing the need for work life balance, the company offers paid eight holiday and accumulative PTO hours of up to 28 days their first year. Employees are eligible for other benefits including but not limited to life insurance, short-term disability insurance, long-term disability insurance, flexible savings accounts, etc. A car allowance is also included.

About ROI Search Group:

ROI Search Group is a woman-led staffing firm based in Fishers, IN. We provide comprehensive staffing solutions including direct hire, contract, and contract-to-hire in addition to other specialized and executive searches. Our unique methodology enables us to attract top talent and support candidates' career progression, aligning with our clients' and candidates' priorities to create mutual success.

At ROI Search Group, we are committed to fostering a workplace that values and celebrates diversity. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or veteran status. We embrace the principles of equal employment opportunity and encourage all qualified candidates to explore career opportunities with us. We believe that a diverse and inclusive workforce enhances our creativity, innovation, and overall success. Join us in our commitment to equality and opportunity.