Medicaid Investigations Manager - Program Integrity

State of Georgia; 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

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.