Manager, Special Investigations Unit at HMSA

Honolulu, Hawaii, United States -

Full Time

Start Date

Immediate

Expiry Date

19 May, 26

Salary

0.0

Posted On

18 Feb, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Program Oversight, Regulatory Compliance, Investigation, Risk Management, Vendor Management, Cross-Functional Collaboration, Leadership, Staff Development, Performance Monitoring, Crisis Management, Program Development, Regulatory Interpretation, Microsoft Office

Industry

Insurance

Description

1. Program Oversight/Leadership for FWA SIU: * Provide strategic oversight of the FWA SIU program * Ensure compliance with all applicable FWA regulatory requirements * Maintain independence and objectivity of SIU investigations * Oversee intake, prioritization, and outcomes of investigations * Review and approve investigative findings and referrals * Escalate significant FWA risks to executive leadership * Oversee vendor and delegated FWA/SIU activities * Monitor FWA trends, metrics, and program effectiveness * Oversee FWA related reporting * Support audit readiness and regulatory inquiries 2. Cross-Functional Team Partnerships: * Partner with Compliance to ensure regulatory alignment and audit readiness * Collaborate with Medical Management on utilization and clinical FWA risks * Coordinate with Provider Relations on provider actions and remediation * Work with Finance on recoveries, overpayments, and financial reporting * Coordinate with Legal as appropriate on investigations, and enforcement actions * Support Operations with FWA education, guidance, and risk mitigation * Coordinate with delegated entities and vendors on FWA oversight and reporting * Serve as the primary SIU liaison to internal and external stakeholders 3. Leadership: * Selects, trains, develops and organizes staff. * Monitors overall inventory of work and prioritizes the staff's work to meet performance standards and authorizes additional resources as needed. * Provides feedback and coaching (helping individuals to solve problems/issues on their own) including timely completion of any interim and year-end performance reviews. 4. Performs all other miscellaneous responsibilities and duties as assigned or directed. #LI-Hybrid Qualifications 1. Bachelor's degree and five years of related work experience; or equivalent combination of education and work experience. 2. Three years of supervisory or management experience. 3. Effective verbal and written communication skills. 4. Collaborative crisis management skills. 5. Ability to develop programs based on relevant industry best practice and regulations. 6. Interpretation of government regulations and applicable codes to ensure compliance. 7. Basic working knowledge of Microsoft Office application, including word, excel, powerpoint, outlook.

Responsibilities

This role involves providing strategic oversight and leadership for the Fraud, Waste, and Abuse Special Investigations Unit (FWA SIU) program, ensuring regulatory compliance and managing all aspects of investigations from intake to referral. The manager will also partner extensively with various internal departments like Compliance, Medical Management, Finance, and Legal to address FWA risks and coordinate enforcement actions.