Job Summary - Manager Special Investigation Unit

The SIU Manager is responsible for leading and managing the Special Investigation Unit (SIU) with a focus on identifying, investigating, and resolving health insurance fraud, waste, and abuse (FWA). This role provides operational oversight to the SIU team, ensuring the effective execution of investigative strategies and compliance with regulatory requirements.

Key responsibilities include managing vendor relationships, overseeing regulatory reporting, and implementing new investigative programs and FWA training initiatives. The SIU Manager collaborates closely with the Director to establish program priorities, set strategic goals, and align departmental objectives with broader organizational initiatives.

Additionally, the SIU Manager represents the organization at state and federal task force meetings, serving as a key liaison with regulatory bodies, law enforcement agencies, and other external stakeholders.

Essential Functions - Manager Special Investigation Unit

Effectively manage the day-to-day operations of the Special Investigation Unit (SIU), ensuring timely and thorough investigation of potential fraud, waste, and abuse (FWA) cases. Provide coaching, mentoring, and training to SIU staff, and deliver FWA training to key departments across the organization

Direct and oversee a broad range of investigations and audits related to FWA, including medical and pharmacy claims, as well as concerns involving members, agents, and employer groups. Ensure accurate documentation, summarization, and reporting of findings.Implement, and continuously refine audit plans to proactively identify FWA risks. Ensure all investigative and audit activities comply with applicable regulatory and compliance standards.Serve as a point of contact for external entities such as the U.S. Attorney’s Office, Office of Inspector General (OIG), state regulators, CMS, and provider organizations. Respond to inquiries and coordinate information sharing related to FWA investigations.Cross-departmental collaboration: Partner with internal departments such as compliance. legal, claims, provider and others as needed to support enterprise wide FWA mitigation strategies and audit support.Review and manage departmental policies, procedures, and job aids to ensure alignment with regulatory requirements. Provide feedback on provider agreements, member materials, and other internal documents that impact the fraud and abuse program.Monitor and evaluate changes to government program requirements, providing feedback and recommendations to ensure compliance and program integrityInterpret audit results and assist health plan leadership in developing and implementing appropriate corrective actions to address identified risks.

Qualifications - Manager Special Investigation Unit

Required Bachelor's Degree Healthcare, Nursing or Business10 years of relevant experience fraud and abuse experience or equivalent combination of; auditing, healthcare fraud and abuse, compliance, or regulatory (i.e., CMS & Medicaid) experience Required5 years of relevant experience An in-depth understanding of provider payment methodologies and concepts (DRGs, capitation, RBRVS payments, APC, percent of charges, etc.) Required5 years of relevant experience Management experience Required7 years of relevant experience Experience working with government programs including Medicare, Medicaid and FEHB Required5 years of relevant experience Well versed with Michigan regulations related to insurance fraud and abuse PreferredUnderstanding and experience with SIU key performance indicators Preferred5 years of relevant experience Direct experience in hospital or physician billing, or equivalent experience with a managed care payer. PreferredPreferredCRT-Accredited Health Care Fraud Investigator (AHFI) - NHCAA National Health Care Anti-Fraud Association preferredCRT-Coding Specialist, Certified-Physician Based (CCS-P) - AHIMA American Health Information Management Association preferred OrCRT-Professional Coder - AAPC American Academy of Professional Coders preferred OrCRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association preferred OrCRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association preferred Or

Physical Demands - Manager Special Investigation Unit

Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbsWaist to Waist > 5 lbs: Seldom up to 10 lbsWaist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbsWaist to Overhead > 5 lbs: Seldom up to 10 lbsBilateral Carry > 5 lbs: Seldom up to 10 lbsUnilateral Carry > 5 lbs: Seldom up to 10 lbsPushing Force > 5 lbs: Seldom up to 10 lbsPulling Force > 5 lbs: Seldom up to 10 lbsSitting: FrequentlyStanding: OccasionallyWalking: OccasionallyForward Bend - Standing: SeldomForward Bend - Sitting: OccasionallyTrunk Rotation - Standing: SeldomTrunk Rotation - Sitting: OccasionallyReach - Above Shoulder: SeldomReach - at Shoulder or Below: SeldomHandling: OccasionallyForceful Grip > 5 lbs: SeldomForceful Pinch > 2 lbs: Seldom

How Corewell Health cares for you

Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.

On-demand pay program powered by Payactiv

Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!

Optional identity theft protection, home and auto insurance, pet insurance

Traditional and Roth retirement options with service contribution and match savings

Eligibility for benefits is determined by employment type and status

Primary Location

SITE - Priority Health - 1231 E Beltline - Grand Rapids

Department Name

PH - Special Investigations Unit

Employment Type

Full time

Shift

Day (United States of America)

Weekly Scheduled Hours

40

Hours of Work

8:00 a.m. to 5:00 p.m.

Days Worked

Monday to Friday

Weekend Frequency

N/A

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Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.