Director of Healthcare Fraud Prevention

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: Directly supervise SIU staff, including hiring, directing, planning work, managing performance, and professional development.
  • Fraud Prevention and Detection: Maintain oversight of and consistency in the deployment of the Company's internal and external fraud awareness training and communication programs.
  • Compliance and Risk Management: 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.
  • Collaboration and Partnerships: Leverage partnerships with other business units and departments to develop, implement, and enhance enterprise-wide approaches to fraud detection and prevention.
  • Performance Metrics and Reporting: Establish and regularly report metrics for the SIU. Report on SIU activities and performance to appropriate management committees.
  • Investigation and Case Management: 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.
  • Policies and Procedures: Direct the creation, modification, and implementation of policies, procedures, methods, and systems required for the prevention, detection, and investigation of fraud and abuse.
  • Communication and Training: Lead team in communication and training sessions for providers when appropriate.
  • Relationship Building: 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.
  • Database Management: Responsible for the database system; maintain, monitor, and analyze operating results and report results to leadership.
  • Business Planning: Plan/forecast for SIU to meet future business needs, including commercial and government program lines of business.
Requirements
  • Education: Bachelor's Degree in Accounting, Finance, Management, Nursing, Criminal Justice, or similar field of study.
  • Experience: 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.
  • Certifications: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred. Certified Public Accountant (CPA) or Registered Nurse (RN) preferred.
  • Skills: Experience creating and implementing a healthcare anti-fraud program. Knowledge of healthcare claims and anti-fraud software tools. Comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions.
What We Offer
  • Medical, Vision, and Dental Coverage
  • Life and Disability Insurance
  • Retirement Programs
  • Wellness Incentives
  • Tuition Assistance
  • Generous Paid Time Off

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