The Georgia Department of Community Health (DCH) is one of Georgia's four health agencies serving the state's growing population of over 10 million people. DCH serves as the lead agency for Medicaid, oversees the State Health Benefit Plan (SHBP) and Healthcare Facility Regulation, impacting one in four Georgians.
Through effective planning, purchasing and oversight, DCH provides access to affordable, quality health care to millions of Georgians, including some of the state's most vulnerable and under-served populations.Six enterprise offices support the work of the agency’s three program divisions. DCH employees are based in Atlanta, Cordele and across the state.
DCH is committed to providing superior Customer Service and Communication, embracing Teamwork and fostering Accountability to ensure that our internal and external customers and stakeholders feel included, respected, engaged and secure.
The Georgia Department of Community Health (DCH) is currently seeking qualified applicants for the position of Investigations Manager, in the Office of Inspector General, Program Integrity Unit.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. This is a hybrid position that requires in-office and remote work with the approval of the supervisor. The days and frequency in the office can change at any time during employment based on the business needs of the organization.
The Investigations Manager shall perform the following duties and responsibilities:
Preferred Qualifications:
POST Certified.
REID Technique for Interview and Interrogation.
M.S. degree in Nursing, Psychology, Healthcare Administration, or similar clinical programs.
Certified Fraud Examiner or Accredited Health Care Fraud Investigator.
Experience with monitoring, investigations, case management, identifying and reviewing claims and auditing of government health care programs.
Experience in the preparation, review and delivery of formal medical/investigative reports including relevant statistical summaries and qualitative analysis of findings.
Knowledge of statistical data and reporting.
Knowledge of Georgia Medicaid and the MMIS System.
Knowledge of both Fee for Service and Managed Care Claims data.
Key Competencies:
Minimum of three years' experience conducting fraud, waste, and abuse reviews/investigations.
Minimum of three years supervisory experience.
Knowledge of Medicaid policies and procedures.
Minimum three years’ experience writing/reviewing fraud reports/investigations.
Experience with monitoring performance guarantees in vendor contracts.
Experience working with Medicaid and/or Medicare claims.
Knowledge of and history of work with medical claims and data.
Proficient in Excel, Access, Data Analysis and Microsoft product.
Must possess excellent writing skills.
Ability to mentor and perform staff development to identify and address performance issues.
Ability to implement courses of actions to ensure compliance with federal and state regulations, and Medicaid policies and procedures.
Ability to organize and manage program areas to mitigate fraud, waste, and abuse in the Medicaid program while protecting the payment integrity of claims.
Ability to set goals with defined milestones to measure progress to monitor key performance metrics.
Ability to counsel subordinates when necessary and develop performance improvement plans to address opportunities for improvement.
EARN MORE THAN A SALARY! In addition to a competitive salary, the Georgia Department of Community Health offers a generous benefits package, which includes employee retirement plan; paid holidays annually; vacation and sick leave; health, dental, vision, legal, disability, accidental death and dismemberment, health and child care spending account.
Due to the volume of applications received, we are unable to provide information on application status by phone or e-mail. All qualified applicants will be considered, but may not necessarily receive an interview. Selected applicants will be contacted by the hiring agency for next steps in the selection process. Applicants who are not selected will not receive notification.
THIS POSITION IS SUBJECT TO CLOSE AT ANY TIME ONCE A SATISFACTORY APPLICANT POOL HAS BEEN IDENTIFIED. APPLICATIONS WITHOUT WORK EXPERIENCE LISTED WILL NOT BE CONSIDERED. CURRENT GEORGIA STATE GOVERNMENT EMPLOYEES WILL BE SUBJECT TO STATE PERSONNEL BOARD (SPB) RULE PROVISIONS. THE POSITION MAY BE FILLED AT A LOWER OR HIGHER POSITION LEVEL.
This position is unclassified and employment is at-will. Candidates for this position are subject to a pre-employment background history, reference check, and credit check.
For more information about this job contact: : http://dch.ga.gov