Manages Special Investigation Unit (SIU) functions which includes detecting, investigating, and remediating incidents of fraud, waste and abuse (FWA), referring incidents to state regulatory agencies and/or law enforcement, as appropriate. Such incidents are related to medical, behavioral, dental, transportation, pharmacy and other healthcare services; sales and enrollment allegations; and internal investigations. Also responsible for case development, case review, overpayment recoveries, state agency and/or law enforcement referrals. Provides training to VNSNY CHOICE employees on FWA detection and prevention. Coordinates with other departments to mitigate and remedy FWA and non-compliance. Works under general supervision.
- Manages day-to-day activities of the Special Investigation Unit (SIU) for VNSNY CHOICE health plan products. Oversees the work of indirect reports related to SIU activities.
- Performs fraud, waster and abuse (FWA) investigations, investigations of sales and enrollment allegations, and internal investigations. Responds to investigations or inquiries from external governing agencies regarding FWA in a timely manner.
- Develops and implements plans for prospective and retrospective FWA avoidance, detection, investigation, and recovery, including managing relationships with outside vendors who may perform some of that function.
- Seeks and tracks recoveries from providers and vendors when necessary and maintains appropriate documentation of the process.
- Completes and submits all required reports on a timely basis to relevant regulatory agencies as directed.
- Presents and reports to the Compliance Committee and other applicable governing entities.
- Coordinates special investigation unit (SIU) activities with other departments, providers, members, vendors, regulatory and law enforcement agencies.
- Assists in development and presentation of FWA training processes.
- Reviews and revises the FWA Detection Manual and related policies to ensure they remain up-to-date and compliant with relevant guidelines.
- Participates in external regulatory meetings and calls as appropriate.
- Reports on any identified patterns of FWA.
- Ensures that investigatory records are appropriately maintained and updated.
- Represents VNSNY CHOICE’s Compliance Department in Credentialing Committee activities; works with the Provider Relations Department to ensure that exclusion checks and sanctions are implemented wherever appropriate.
- Demonstrates a high level of integrity through appropriate treatment, confidentiality, and security of proprietary information, protected health information, and CMS and/or DOH sensitive information.
- Participates in special projects and performs other duties as assigned.
EDUCATION: Associates or bachelor’s degree in Criminal justice or health care field preferred. Certified Fraud Examiner (CFE) designation awarded by Association of Certified Fraud Examiner preferred.(ACFE) preferred.
EXPERIENCE:Minimum of five years of insurance claims investigation experience or seven years of professional investigation experience involving economic or insurance related matter required. Strong knowledge of Medicare, Medicaid statutes, regulations, and policies required. Excellent analytical, communication and organizational skills required. Excellent investigative and problem-solving skills required. Demonstrated ability to interpret data, program requirements, and conceptualize, analyze, and disseminate information in a readily understandable manner required. Strong mentoring skills and the ability to work in a collaborative environment preferred.
The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.