MCNA Dental, a leading dental benefit management is seeking a Director of Special Investigations. The candidate is responsible for overseeing the company’s anti-fraud program and the overall operation of the Special Investigations Department. Reports to Executive Management and advises on all potential fraud, waste or abuse risk, exposure, or recovery to the company.
Oversees overall direction and operation of the Special Investigations Department, including all fraud, waste and abuse prevention and detection activities, with specific focus on government sponsored programs (e.g., Medicaid, CHIP and Medicare).
Determines, recommends or implements actions necessary to maximize investigative results.
Maintains service standards, reporting procedures, statutory compliance and operations of the department.
Maintains confidentiality, within the department in compliance with Health Information Portability and Accountability Act (HIPAA).
Monitors system designed to maintain and analyze fraud related data and statistical information related to fraud prevention efforts.
Monitors investigative workloads and resources and determines when adjustments are warranted.
Develops and facilitates communication within the industry for identification of significant fraud-related issues.
Assures appropriate coordination and cooperation with internal and external contacts,
Creates lines of communication with regulatory agencies, sensitizing them to the dental insurance fraud schemes.
Maintain outside contacts that ultimately provide benefit to the Company, make recommendations for implementation of measures that help to prevent recurring fraud and abuse, establish priorities and follow up on complex projects.
Exercises decision in the control, coordination, direction and evaluation of the department operations, including the approval or disapproval of critical investigative actions, after consultation with VP of Program Integrity.
Directs performance management, training and development, workflow and organizational planning, hiring and placement, and disciplinary actions.
Keeps abreast of current developments in health care fraud arena.
Collaborates with the Chief Compliance Officer and General Counsel on all recoveries and settlement agreements.
Develops and implements policies and procedures.
Keeps current with professional education and certifications.
Plans and prepares all fraud training and company awareness anti-fraud activity, files regulatory reports as required in a timely manner.
Represents the company at state meetings and professional organizations.
Performs all other duties as assigned.
Bachelor’s degree in Criminal Justice or a health related field - required
10 years professional experience in investigations - preferred
5 years of supervisory/management experience - required
3 years professional experience in healthcare investigations - preferred
Certified as a CFE or AHFI or any other law enforcement certifications - preferred
Advanced MS Excel and MS Word skills required
Knowledge & Skills:
Must present a high degree of initiative, mature judgment and discretion.
Knowledgeable of regulations established by the Center for Medicare & Medicaid Services (CMS) and state Medicaid agencies.
Must have the ability to resolve conflicts and empathize with others
Strong negotiating skills.
Demonstrate the ability to handle confidential information in a professional manner in compliance with HIPAA regulations.
Experience working on and leading cross-functional projects or with cross functional project teams.
Ability to maintain confidentiality.
Strong communication and relationship building skills required.
Strong knowledge of the health care regulatory processes and functions.
Ability to use critical thinking skills to interpret, evaluate, clarify and explain complex processes and requirements to senior-level management and business partners with the intent to identify and mitigate regulatory compliance issues.
Excellent writing, executive presentation, verbal communication, facilitation, decision-making, time management and interpersonal skills, and detail oriented.
Exceptional organizational and leadership skills.
Experience working independently and responding to rapidly changing priorities.
Ability to work under pressure and within strict time frames. Forward thinking and follow through
This is a full time position with a competitive salary based upon experience and qualifications. Some of the benefits MCNA offers are medical, dental, vision, Colonial, company paid life insurance, 401k, as well as paid vacation, sick and holiday time.
MCNA is an Equal Opportunity Employer -----M/F/D/V
Please check out our website: www.mcna.net
“It’s a great day at MCNA!”