Fraud Investigations Manager – Health Care

Remote, North Carolina

Who we are:

Constellation Quality Health, formerly CCME, is a non-profit health care quality organization and QIO-like Entity certified by the Centers for Medicare & Medicaid Services (CMS) founded by physicians in 1983. Headquartered in North Carolina’s Research Triangle, we offer an array of quality improvement, clinical review, audit, technical, and consulting services and solutions to improve care delivery, system performance, and patient outcomes.

What you’ll do:

We are seeking a Fraud Investigations Manager to be responsible for providing oversight and management of health care fraud investigations in support of client fraud, waste, and abuse (FWA) contracts.

We expect you to:

• Assign, review, and approve investigative and analytics work products for health care fraud investigations in support of client FWA contracts.
• Lead efforts to proactively identify FWA with the assistance of predictive fraud analytics tools in support of client FWA contracts.
• Assist in the development of new FWA client relationships through outreach, conference attendance, networking, and business associations.
• Ensure compliance with applicable contractual requirements, and federal and state regulations.
• Monitor and evaluate the quality, timeliness, and accuracy of team processes.
• Train staff, assign work, and resolve complex FWA issues to ensure accurate, cost effective and compliant operations.
• Support arbitrations, legal procedures, and settlements.
• Interact with clients and regulatory and/or law enforcement agencies regarding case investigations.
• Develop FWA market landscape presentations for internal and external customers.
• Develop professional reports on a regular cadence for internal reporting and in keeping with contract requirements
• Play a key role in Business Development activities including RFP/Grant response development, outreach and engagement, opportunity identification, product development, and presenting to internal and external audiences of various size and professional level.
• Operate as a positive member of the investigations, PI, and Program Solutions teams, ensuring a culture of cooperation, mutual support, professionalism, and high reliability.
• Travel within the U.S. required for customer meetings and conferences.

This position is contingent upon contract award and works remotely.

Who You Are

The Fraud Investigations Manager is an expert in health care fraud investigations with a high attention to detail. The successful candidate must understand current and future trends in health care fraud, waste, and abuse, population health, and reimbursement.

Our requirements for this role:

• Bachelor’s Degree required.
• Master’s Degree preferred.
• Prior law enforcement experience highly preferred (FBI, HHS-OIG, state or local law enforcement).
• 7+ years of health care general fraud investigations related experience including SIU or FWA programs.
• Minimum 3 years’ FWA team management experience, including supervision, training, recruitment and retention, meeting facilitation, and follow through on deliverables.
• Minimum 3 years’ experience writing public-facing reports and presenting on a regional or national level required.

Why Constellation Quality Health:

We offer a competitive salary and benefits package and a flexible work environment.

• Equal opportunity employer of protected veterans.
• Equal opportunity employer of individuals with disabilities.
• We do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, gender identity, national origin, medical condition, disability, veteran status, or any other basis protected by law.
• Applicants and employees are protected from discrimination based on inquiring about, disclosing, or discussing compensation or the compensation of other applicants or employees.