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AmeriHealth Caritas Director Special Investigations Unit (SIU) in Philadelphia, Pennsylvania

Director Special Investigations Unit (SIU)

Location: Philadelphia, PA

Telecommuter?: No

ID**: 19066

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .

Responsibilities:

The Director, Special Investigations Unit (SIU) is accountable to the Corporate Compliance Officer and is a leadership position requiring internal and external presence reflecting high integrity and clear accountability for anti-fraud management across AmeriHealth Caritas Medicaid, Medicare, Pharmacy Benefits Management and Behavioral Health.

Primary Responsibilities and Accountabilities are:

  • Lead SIU comprised of SIU managers, supervisors and healthcare anti-fraud investigators spanning all plans and products in the enterprise.

  • Chair the Fraud, Waste and Abuse Committee in effectively reporting and communicating trends at the local and corporate level.

  • Day-to-Day leadership and management of the staff and caseloads is critical, therefore a disciplined approach to triage from Referrals and Validation in conjunction with internal and vendor data mining queries is essential.Lead the triage and case management process that maximizes recoveries and referrals for ACFC while concurrently documenting all cases with criteria that enables high quality internal and external regulatory audit.

  • Work closely with each market president and the corporate and local compliance leadership, and other key operational and clinical staff to communicate potential fraud and abuse that may be taking place within the respective plans.Develop and execute plans in collaboration with the market presidents.

  • Work closely with state and federal program integrity organizations, and the Medicaid Fraud Control Unit (MFCU), MEDIC, or other agencies in representing the AmeriHealth Caritas Family of Companies.

  • Ensure continued movement of cases from identification to referral, recovery or close.

Education/ Experience:

  • Bachelor’s Degree.

  • Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI).

  • 10 or more years experience.

  • Strong leadership and communications skills.

  • Proven track record in maneuvering across matrix organization.

EOE Minorities/Females/Protected Veterans/Disabled

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