Investigations Manager

Community Health, Department of; High Springs (FL); On-site; USD 56,000 - 80,000; Full time

Job summary

State of Georgia's Department of Community Health seeks an Investigations Manager to lead a two-person team focused on fraud detection and abuse in Medicaid. The role involves data analysis, on-site investigations, and coordinating utilization reviews to safeguard program integrity.

Applicants should bring a relevant degree and substantial supervisory experience. The position reports to the Department of Community Health and entails collaboration across Georgia state government.

Qualifications

• Bachelor’s degree in operations management, business administration, or related field with 3+ years in a supervisory role.
• Seven years of related professional experience including 3 years in a managerial capacity.
• Equivalent combinations of knowledge, education, or experience may be substituted year-over-year.

Responsibilities

• Manage two direct reports in investigating fraud, waste, and abuse in the Medicaid program.
• Analyze claims data to identify aberrant billing trends for utilization review.
• Conduct on-site visits to providers to request records and verify equipment and services billed.
• Review referrals and hotline complaints; participate in Surveillance Utilization Review meetings.

Skills

Leadership

Policy compliance

Analytical thinking

Data analysis

Education

Bachelor's degree in operations management, business administration, or related field with 3+ years in a supervisory role

Tools

Claims data analysis

Job description

Explore a World of Opportunity with the State of Georgia! We are the force that drives Georgia! Georgia State Government is a large enterprise, composed of various agencies and entities with a common goal to improve the lives of Georgia's more than 10 million citizens! Join Team Georgia and impact lives everyday while receiving a robust benefits package designed for every stage of your career!

Job Information

Job Title: Investigations Manager

Agency: Department of Community Health

Job Requisition ID: JR0000004059

Shift: Not Applicable (United States of America)

Compensation Details: $56,310.72 - $80,000

Job Description

The position provides critical support functions within the Program Integrity Unit and the Office of Inspector General, which helps safeguard the agency from fraud, waste, and abuse. The selected candidate will be responsible for managing two (2) direct reports charged with investigating providers for fraud, waste, and abuse in the Fee-for-Service Medicaid program. The Investigations Manager provides guidance and feedback to the team to ensure adherence to performance metrics and timeliness of business processes for the Program Integrity Unit. The Investigations Manager analyzes claims data to identify aberrant billing trends for providers to facilitate utilization review. The Investigations Manager conducts and leads provider on sites throughout Georgia to request medical records, conduct interviews, and tour facilities to ensure appropriate medical equipment is onsite to support services billed to Medicaid. The Investigations Manager reviews documentation for Participant and Consumer Directed Care services to investigate allegations of false claims billed to Medicaid. The Investigations Manager reviews referrals, hotline complaints, and participates in Surveillance Utilization Review meetings to identify providers for utilization review.

Minimum Qualifications

• Bachelor's degree in operations management, business administration, or a related field which includes three (3) years in a managerial or supervisory role;
• seven (7) years of related professional experience which includes three (3) years in a managerial or supervisory role;
• or three (3) years of experience required at the lower level Mgr, Business Ops (GSM010) or position equivalent.--Note: An equivalent combination of knowledge, education, job or intern experience, training, or certifications that provides the necessary knowledge and skills to successfully perform the job at the level listed may be substituted year-over-year.

Equal Employment Opportunity

Equal Employment Opportunity Employer The State of Georgia does not discriminate based on race, color, national origin, sex, religion, age, disability, or other protected categories in employment or the provision of services.

Qualified applicants may request reasonable accommodation when needed during the application and/or screening process by contacting the appropriate agency Human Resources department.

Georgia State Government is a large enterprise, composed of various entities with a common goal to improve the lives of Georgia's 10 million citizens. With nearly 62,000 employees, we are one of the single largest employer in the state. Public service opportunities stretch across the state as employees live and work in all 159 counties. From traditional fields such as accounting, nursing, and engineering to unique fields like forestry and natural resources management, Georgia state government provides a world of opportunity.