|Location: Lee’s Summit, MO
Assists the Manager of the Special Investigations Unit (SIU) in ensuring that the Plan is in compliance with OPM contract requirements to identify, investigate, report, and manage medical fraud, waste and abuse (“FWA) cases. Coordinates with the SIU team to investigate allegations of FWA cases and document case status per department policy. Delegates investigations to contract investigators when appropriate. Creates appropriate OPM OIG notifications and communicates with OIG as needed. Refers cases to federal and state agencies, law enforcement, and appropriate professional organizations in consultation with the SIU Manager. Develops and maintains effective relationships with the OPM IG office and other appropriate external partners. Participates in organizational FWA training. Ensures that the SIU Manager is kept apprised of significant issues/developments.
• Coordinates with SIU team in identification of appropriate cases for deeper investigation.
• Becomes proficient in use of the FWA tool and uses the information to develop enrich case work under investigation.
• Ensures that all assigned cases are fairly and thoroughly investigated and brought to their appropriate conclusion. Completes documentation per department policy in a timely and through manner.
• When needed and approved by the SIU Manager ensures that appropriate contract investigative personnel are engaged to assist in the investigations. Responsible for briefing external investigator on case particulars, development a documented case action plan, and initiation of regular follow up until case is concluded.
• In consultation with department policy, creates OPM IG notifications, with all required documentation elements, and provides follow-up information as required/requested.
• When appropriate and in consultation with the SIU Manager, takes the responsibility for referring assigned FWA cases to federal and state agencies, law enforcement, and appropriate professional organizations.
• Assist the SIU Manager in the development, as necessary, for the FWA manuals required by OPM contract and industry standards.
• Takes an active role in NHCAA Membership Forum and other approved organizations to receive current information on health care fraud. Build relationships with carriers and law enforcement through NHCAA membership.
• Participates in OPM OIG quarterly carrier meetings devoted to FWA issues, to keep updated with current major investigations, reporting requirements and case sharing.
• Responsible for developing relationships with OPM OIG investigators as well as other federal and state agencies, and law enforcement agencies.
• Participates in FWA training throughout the GEHA organization as directed by the SIU Manager.
• Requires a Bachelor's Degree.
• Requires a minimum of five years of investigative experience with a Federal, state or local law enforcement agency.
• Requires 3 years of experience investigating health care fraud.
• Requires the ability to use a personal computer and MS Word and MS Excel.
• Experience working in/with a Special Investigations Unit is preferred.
GEHA is an Equal Opportunity Employer. GEHA will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant.
Our company's corporate headquarters is located in Lee's Summit near Douglas Rd and I-470 with a total of five locations in the Kansas City metropolitan area.