Director, SIU

PURPOSE: The Director, Special Investigation Unit (SIU) is responsible for developing and executing organizational strategies for the SIU and provides management oversight of the investigative team from the research and planning phase through the disposition of fraud, waste, and abuse matters and/or cases. The Director ensures the team's investigative caseload is effectively and efficiently managed, as well as assigned and closed in a timely manner. The Director is the face of the SIU, and works closely with counsel, as well as local and federal law enforcement and antifraud professionals. ESSENTIAL FUNCTIONS: Develop and implement a short and long-term anti-fraud, waste, and abuse investigations strategy. Design and build related processes, including the teams responsible for identifying and investigating suspicious financial and non-financial activity involving allegations of misconduct by employees, providers, agents, customers, members, and/or vendors. Perform continuous reviews of the SIU’s anti-fraud, waste, and abuse programs and practices for investigations to ensure statutory and regulatory compliance. Ensure continued movement of SIU investigations from identification to case, referral, recovery and/or close. Work with other functional areas of the company to improve anti-fraud, waste, and abuse activities, including with underwriting and corporate audit. Work closely with internal and external counsel to develop and implement appropriate case strategies to represent the company. Oversee and manage pre-litigation and litigation support for SIU-generated matters, including preparation of appropriate reports and evidentiary support needed to present robust and defensible positions in court. Lead the triage and case management process that maximizes the SIU’s resolution strategy, including recoveries, while concurrently enabling high-quality case documentation that can withstand internal and external audit.  Work closely with internal functional areas and divisions, including audit, compliance, risk management, and legal, as well as other key operational and clinical staff, to communicate potential fraud, waste, and abuse activity and to develop strategies and policies to resolve such activity. Develop and execute anti-fraud, waste, and abuse plans in collaboration with functional and division leaders. Represent the company and work closely with local, state, federal, and national program integrity and anti-fraud, waste, and abuse organizations, such as the NHCAA, the BCBSA, FEP, local Medicaid Fraud Control Units (MFCU), MEDIC, and/or other local, federal, or national agencies. SUPERVISORY RESPONSIBILITY: This position manages people. QUALIFICATIONS: Education Level: Bachelor's Degree Experience: 8 years experience in forensic analysis, fraud detection and 3 years of management experience Knowledge, Skills and Abilities (KSAs) Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging. Department Department:  Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.