Senior Manager, Special Investigations Unit

7 days ago

Mountlake Terrace, Washington, United States Premera Blue Cross Full time
Job Summary

We are seeking a highly experienced Senior Manager to lead our Special Investigations Unit (SIU) in driving the development, implementation, and communication of fraud prevention, detection, investigation, reporting, and recovery strategies designed to support organizational goals and objectives.

The successful candidate will have a proven track record of success in anti-fraud efforts, with a minimum of 8 years of experience in healthcare fraud investigations, including 3 years of related SIU/criminal management experience.

Key Responsibilities
  • Lead the SIU in developing and implementing fraud prevention, detection, investigation, reporting, and recovery strategies.
  • Directly supervise SIU staff, including hiring, directing, planning work, managing performance, and professional development.
  • Maintain oversight of and consistency in the deployment of the Company's internal and external fraud awareness training and communication programs.
  • Chair the SIU Steering Committee.
  • Maintain an awareness of applicable statutory laws, regulations, and judicial developments, and in conjunction with Premera's internal legal counsel, assure the Company's compliance with applicable legal, regulatory, and contract anti-fraud requirements.
  • Leverage partnerships with other business units and departments to develop, implement, and enhance enterprise-wide approaches to fraud detection and prevention.
  • Manage the day-to-day department performance including case assignments, case development, case review, overpayment recoveries, law enforcement referrals, training of staff, and coordination with other departments.
  • Establish and regularly report metrics for the SIU. Report on SIU activities and performance to appropriate management committees.
  • Lead team in investigations and monitor investigation quality by providing technical assistance in case development, serving as the Company's representative during formal proceedings when necessary and reviewing and approving dispositions of cases.
  • Direct the creation, modification, and implementation of policies, procedures, methods, and systems required for the prevention, detection, and investigation of fraud and abuse, including evaluating business technology requirements and recommending viable tech solutions, modifications, and/or enhancements to support anti-fraud efforts.
  • Lead team in communication and training sessions for providers when appropriate.
  • Foster and maintain positive relationships and coordination with representatives of the Company core functions, policyholders, law enforcement, other Blue Cross Blue Shield Plans, other commercial health plans, and the general public.
  • Responsible for the database system; maintain, monitor, and analyze operating results and report results to leadership.
  • Plan/forecast for SIU to meet future business needs, including commercial and government program lines of business.
  • As part of this role, you may be assigned internal controls derived from Premera's internal controls framework. You will be accountable for understanding the controls assigned to you, their impacts on Premera, and to ensure that they are operating effectively.
  • As part of this role, you may have responsibility for the oversight of third parties. You will be accountable for ensuring the third parties assigned to you operate effectively, in compliance with their contract and Premera's Third Party Code of Conduct, and that you and the third parties complete all assigned mitigation activities in a timely and accurate manner.
Requirements
  • Bachelor's Degree in Accounting, Finance, Management, Nursing, Criminal Justice, or similar field of study.
  • (8) years of experience with anti-fraud with specific experience involving healthcare fraud, including a minimum of (3) years of related SIU/criminal management experience with healthcare investigations.
  • Master's Degree in Accounting, Finance, Management, Nursing, Criminal Justice, or similar field of study preferred.
  • Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred.
  • Certified Public Accountant (CPA) or Registered Nurse (RN) preferred.
  • Experience creating and implementing a healthcare anti-fraud program.
  • Knowledge of healthcare claims and anti-fraud software tools.
  • Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions.
  • Proven ability to communicate complex subjects to all levels of employees, management, and external contacts.
  • Excellent communication and negotiation skills, as well as the capability of taking the lead in interviews with suspects and/or their attorneys.
  • Strong technical writing skills demonstrating the ability to write reports and business correspondence and to prepare case files.
  • In-depth knowledge of the insurance industry, Special Investigation Unit operations, claims handling and payment operations, and insurance contracts.
  • Ability to interact with others in one-on-one situations to identify issues/problems and provide training/coaching to correct problem areas.
  • Strong problem-solving skills and decision-making abilities.
  • Organizational and team building skills.
What We Offer
  • Medical, vision and dental coverage.
  • Life and disability insurance.
  • Retirement programs (401K employer match and pension plan).
  • Wellness incentives, onsite services, a discount program and more.
  • Tuition assistance for undergraduate and graduate degrees.
  • Generous Paid Time Off to reenergize.
  • Free parking.

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