Job Summary

Responsible for planning, direction, and operation of the Special Investigations Unit (SIU). Responsible for developing and directing the fraud, waste and abuse (FWA) program processes and oversight and coordination of program integrity activities. Serves as point of contact for collaboration with local, state and federal law enforcement and regulatory partners as well as senior executives throughout Priority Health. 

 

Essential Functions 

Responsible for the development, management, implementation and oversight of the Special Investigations Unit. Responsible for the overall direction, performance and supervision of the SIU team. Assumes accountability for the teams’ deliverables, ensuring the achievement of SIU goals and objectives in addition to individual goals and objectives. 

Maintains and revises policies and procedures, fraud, waste, and abuse plans, annual audit work plans, including department guidance memos, and training and educational materials. Partners with other department leaders and Priority Health senior leaders in the planning, and coordination of department specific processes and programs. 

Drives the development of improvement strategies through the audit process and provide recommendations for system enhancement of investigative outcomes and performance. Develops and oversees the production of standard KPIs to monitor and report on overall department metrics and management. 

Oversees the tracking, reporting, and monitoring of overpayments and recoveries. Maintains current, in-depth knowledge of all Priority Health benefits, payment policies, provider network, configuration issues, and industry billing practices. 

Provides direct accountability for SIU case inventory management ensuring all recoveries are processed promptly. Leads business requirement process and reporting to ensure notification of case activity to the appropriate regulatory and/or law enforcement agency. Leads the engagement, identification and escalation framework for SIU. Ensures investigations progress with minimal delays and in adherence with state and/or federal requirements. 

Acts as a catalyst for change and innovation and energizes others to embrace change and transformation of the organization in new and effective directions. Formulates objectives and priorities, and implements plans aligned to Priority Health's mission and long-term interests. Builds a shared vision with others and acts as a catalyst to transform and pursue organizational change. 

Manages external engagements and related requests from federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. Represents the SIU in various state and/or federal FWA related regulatory meetings. Ensures that Priority Health meets its legal and regulatory obligations related to FWA. Makes referrals to and maintains relationships with regulatory and law enforcement officials. 

Motivates others to act by forging positive relationships internally and externally for the strategic benefit and outcome achievement of Priority Health's mission and goals. Demonstrates collaboration, clarity, compassion, curiosity, courage and integrity in all interactions. 

 

Qualifications 

Required Bachelor's Degree in criminal justice or other related field, business, health care administration/operations/management, information technology/information security, nursing or other related field. 

10 years of relevant experience in insurance, health care, technology, investigations, and/or law enforcement. Required 

10 years of relevant experience Supervising/managing people and teams, external delegates and programs. Knowledge of applicable fraud statutes and regulations, and of CMS guidelines. Required 

CRT-Accredited Health Care Fraud Investigator (AHFI) - NHCAA National Health Care Anti-Fraud Association Upon Hire preferred 

CRT-Fraud Examiner (CFE) - ACFE Association of Certified Fraud Examiners Upon Hire preferred 

Physical Demands 

Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs 

Waist to Waist > 5 lbs: Seldom up to 10 lbs 

Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs 

Waist to Overhead > 5 lbs: Seldom up to 10 lbs 

Bilateral Carry > 5 lbs: Seldom up to 10 lbs 

Unilateral Carry > 5 lbs: Seldom up to 10 lbs 

Pushing Force > 5 lbs: Seldom up to 10 lbs 

Pulling Force > 5 lbs: Seldom up to 10 lbs 

Sitting: Frequently 

Standing: Occasionally 

Walking: Occasionally 

Forward Bend - Standing: Seldom 

Forward Bend - Sitting: Occasionally 

Trunk Rotation - Standing: Seldom 

Trunk Rotation - Sitting: Occasionally 

Reach - Above Shoulder: Seldom 

Reach - at Shoulder or Below: Seldom 

Handling: Occasionally 

Forceful Grip > 5 lbs: Seldom 

Forceful Pinch > 2 lbs: SeldomFinger/Hand Dexterity: Frequently 

 

How Corewell Health cares for you

Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.

On-demand pay program powered by Payactiv

Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!

Optional identity theft protection, home and auto insurance, pet insurance

Traditional and Roth retirement options with service contribution and match savings

Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Special Investigations Unit

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8am - 5pm

Days Worked

M-F

Weekend Frequency

N/A

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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.