Health Care that Starts with You!

Join a truly mission-driven organization! Independent, nonprofit UCare is recognized as one of the Minnesota's leading health plans. We provide more than 225,000 members across Minnesota and western Wisconsin with the health coverage plans and services they need to maintain and improve their health. The innovative coverage we create makes a difference for Medicare-eligible individuals, individuals and families enrolled in Minnesota Health Care Programs, such as MinnesotaCare and Medical Assistance, and disabled adults with special health care needs.

UCare is growing in size, membership, products, geographic coverage, and employees. We're an organization that's going places. Be part of a team that cares about you, be part of UCare.

Rewards

Enter a highly collaborative environment where people are truly engaged, and feedback is valued. You'll enjoy a competitive salary and benefits, as well as a host of other perks, including a nationally recognized wellness program, and a bright, open, award-winning office space in Northeast Minneapolis just minutes from major freeways and retail centers.

At UCare, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.

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EOE/AA

ABOUT UCARE

At UCare, we deliver high-quality health coverage and services to help members of all ages maintain and improve their health. It's a big job that takes innovative ideas, strategic partnerships, and a commitment to doing the right thing. Above all, it takes a compassionate team that is dedicated to making a real difference in the lives of our members and our communities.

WORKING AT UCARE

Working at UCare is more than just a career; it's a mission. A mission that defines us as professionals, unites us as an organization, and shapes how we interact with our members and each other. Our values of integrity, community, quality, flexibility, and respect permeate every aspect of our organization - from who we are and how we act, to what we do and how we do it. We owe our continued success to our employees who proudly embody our mission and values in everything they do.

SPECIAL INVESTIGATIONS UNIT MANAGER

Position Description

This position is responsible for leading Special Investigations Unit (SIU) efforts to prevent, detect and resolve suspected fraud, waste and abuse (FWA) by providers or enrolled members, identifying opportunities to strengthen the efficiency and effectiveness of program integrity and act as the liaison with Legal and external authorities. This includes program development and management that provides industry expertise and strategic direction in healthcare FWA; directing staff; providing direction and oversight of investigations; data mining analysis; auditing/monitoring activities; and mandatory regulatory reporting.

Specific duties and responsibilities include:

• Responsible for the SIU strategic direction and leveraging the FWA risk assessments in order to create and monitor the annual FWA work plan.

• Ensures SIU compliance with all state and federal requirements, including, but not limited to: policies and procedures, regulatory and operational reporting, fulfillment of subpoenas and Requests for Information.

• Participates in contract reviews and negotiations as requested by senior leadership. Act as FWA/SIU subject matter expert for delegated oversight audits, and regulatory audits. Lead state SIU preparedness and audit responses.

• Collaborate with business areas to assist in implementation of overpayment recoveries and corrective action for deficiencies identified through investigations, monitoring and auditing activity.

• Conduct and oversee SIU operations, including; collect, review and analyze case evidence such as patient charts, business records, financial ledgers and claims data. Perform analysis of applicable regulations, contracts and policy manuals to determine whether violations exist. Conduct interviews of witnesses or targets, and perform field work including provider site visits and surveillance as needed. Write investigative reports summarizing evidence, investigative activities, and findings. This includes compiling accurate case file documentation and calculation of overpayments. Make referral of findings to law enforcement or regulators as appropriate. Conduct data mining and data analysis using available tools and internal data warehouse. This includes basic to intermediate functionality in Excel or similar software, performing manipulation, sorting, analysis, summarization and presentation of data in an understandable and reliable format.

• Prepare and submit required FWA reporting to regulatory agencies, the Compliance Oversight Committee and the Compliance Committee of the UCare Board of Directors.

• Direct SIU staff in managing workload, assigning tasks, monitoring progress against annual FWA work plans and meeting regulatory timelines, bringing forth issues to Legal, and the VP of Compliance & Internal Audit as necessary. This includes assisting in the development and oversight of staff training, development plans, monitoring performance and coaching employees.

• Coordinate with law enforcement, government agencies in joint investigations, and/or contracted vendors in the investigation of suspected FWA, including act as SIU subject matter expert for court testimony, affidavits, and with regulators.

• Analyze trends and take steps, in collaboration with internal partners, to prevent recurrence. Serve as a resource for departments to research and resolve integrity inquiries and assist in identification of improvements to internal practices that may reduce or prevent FWA. Recommend viable technological solutions, modification, and application to support anti-fraud efforts.
• Maintain an understanding of current state and federal insurance statutes, regulations, and internal policies to ensure compliance. Document and revise SIU policies and procedures to adequately reflect current regulatory and industry standards.
• Participate in the development and delivery of FWA training for UCare employees as well as any required training for first tier and downstream entities.
• Support the initiatives of the Corporate Compliance Department, leveraging cross functional subject matter expertise to improve the overall effectiveness of UCare's Compliance Program.

Education

Bachelor's degree in business, criminal justice, health care or related field.

Required Experience

Three years of experience as a professional investigator, with at least three years' experience in health care fraud, waste, and abuse including Medicaid and Medicare. Three years of experience in leadership role. Experience testifying in civil, criminal, or administrative proceedings. Working knowledge of local, state, and federal laws and regulations pertaining to insurance, medical terminology, and coding. Competency in data analytics, utilizing at least intermediate level Excel.

Preferred Experience

Experience analyzing health care claims data, and experience using data analytics software. Project management and/or process improvement experience.

THE UCARE DIFFERENCE

UCare is proud to be a recognized Star Tribune Top Workplace for the 9th consecutive year. As a part of our collaborative team, you'll experience the rewards that come with helping others and seeing the positive results of your hard work. We value and respect each individual's ideas and contributions, and give you the freedom to grow both personally and professionally. We are centrally located, and offer onsite education, equipment and wellness resources, a myriad of volunteer activities, and a number of other rewards. If you're looking for a welcoming environment that celebrates what you have to offer, helps you build on your strengths, and gives you the opportunity to truly make a difference, we invite you to apply.

As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of UCare, our members, and the communities we serve.