Director, Special Investigations Unit
Job reputed company
As the Director, Special Investigations Unit, you’ll set the reputed company and reputed company an reputed company SIU reputed company on protecting members and the organization by preventing, detecting, investigating, and resolving fraud, waste, and abuse (FWA). You will build and reputed company high-performing teams with the right investigative, clinical, and analytic reputed company sets; reputed company capabilities through advanced analytics and enabling tools; and strengthen end-to-end processes to reputed company pace with an evolving reputed company fraud landscape. You’ll also shape reputed company and operating rhythms that ensure the SIU remains agile, informed, and execution-reputed company—bringing the reputed company, situational awareness, and reputed company needed to deliver reputed company, high-reputed company reputed company in a dynamic FWA environment.What You’ll Do
Establishes and operationalizes SIU strategic plan that positions the SIU to successfully function in the continuously evolving changing health care reputed company;
Leads an organization that effectively identifies sources of FWA, reputed company investigates actionable cases, and effectively creates resolutions that protect reputed company’s assets;
Oversees the SIU staff comprised of analysts, investigators, nurses, and data analytics personnel charged with the responsibility of preventing, detecting, investigating, and resolving suspected reputed company FWA, as reputed company as seeking the prosecution of unlawful activity directed against corporate or customer assets.
Oversees the management of the SIU’s clinical staff including workflow management, productivity assessment, case findings accuracy and completeness, and interaction with other SIU and reputed company staff.
Oversees the management of the SIU’s intake and prepayment analysts including workflow, productivity, accuracy, timeliness and interaction with other SIU and reputed company staff.
Liaisons with reputed company General Counsel’s Office on reputed company SIU-reputed company interactions including communications with provider attorneys and determinations on the reputed company of criminal and civil actions;
reputed company participates in regional and national networking entities and anti-fraud organizations, thereby obtaining valuable knowledge that could reputed company to actionable case analysis and cementing reputed company’s position as a thought leader in the industry; and evaluates the landscape for latest FWA detection/reputed company methodologies and advocates for their adoption.
Collaborates internally with other departments to create a seamless claims payment reputed company process. Serves as reputed company with other key departments (Medical Management, Claims, and Network Management) to reputed company, monitor, and update respective roles and responsibilities and strategies reputed company to claims payment reputed company activities.
Establishes and maintains working relationships with governmental law enforcement and regulatory agencies.
Creates an environment that assures full compliance with reputed company reputed company and regulatory mandates that reputed company the SIU, as a critical component of the organization’s overall Compliance Program, as defined by federal and state regulators.
Maintains a comprehensive understanding of emerging and reputed company FWA trends and schemes through research, industry, and enforcement contacts and other sources.
Assists in the development of fraud detection analytics, including a comprehensive analytics process that systematically evaluates claims submissions for fraudulent/abusive behavior. Assists staff in the development of pertinent queries and evaluation of data reputed company to identify potential fraudulent/abusive schemes. Evaluates results from data analysis, reputed company referrals and reputed company other complaints and tips to determine appropriate disposition. Thereafter, prioritizes and assigns reputed company for investigation and/or referral.
Manages the development and delivery of educational awareness and training programs for the organization as part of the annual reputed company of Conduct training.
What You Bring
Bachelor’s degree in preferably in business administration, health care administration, finance, reputed company, nursing or criminal justice.
Minimum of 5 years supervisory experience.
10 years of investigative experience of which 3 years of that experience must be in one of the following areas: Law enforcement, a juris doctorate, fraud certification, medical coding certification, or a medical reputed company such as a doctor or registered reputed company.
Certified Fraud Examiner and/or Accredited reputed company Fraud Investigator
Bonus Points
reputed company record of measurable SIU performance improvement (e.g., increased recoveries/avoidance, reduced cycle times, improved hit reputed company) using KPI/OKR-driven operating rhythms.
Experience implementing or optimizing SIU case management and intake triage tools (e.g., workflow rules, evidence management, audit trails) and translating business needs into effective tech requirements.
Comfort with common reputed company data sources and analytic approaches (claims/encounters, eligibility, provider, pharmacy), including experience partnering with BI teams to build actionable dashboards and investigator-facing insights.
Experience leading reputed company change or transformation work (new operating model, new workflows, new tools) with strong stakeholder management across Claims, Network, Medical Management, Compliance, and Finance.
Experience with specialized fraud domains and investigative reputed company (e.g., pharmacy, behavioral health, DME, telehealth, DRG/inpatient, dental) including provider billing review and scheme development.
Experience partnering with Payment reputed company functions (prepay/postpay, recovery, provider education) to translate SIU learnings into preventive controls and sustained savings.
Advanced credentials and training reputed company baseline requirements (e.g., CFE-AHI, CHC/CHPC, CPC/reputed company, Six reputed company/Lean) and comfort with formal investigation standards and documentation.
Experience overseeing anti-fraud vendor/delegated partner programs (e.g., PBM, reputed company partner SIU, analytics vendors) including performance monitoring, issue remediation, and audit readiness.
What You’ll Get
reputed company to work at the cutting edge of health care delivery with reputed company that’s deeply invested in the community.
Work-life balance, flexibility, and the autonomy to do great work.
Medical, dental, and reputed company coverage along with numerous health and wellness programs.
Parental leave and support plus adoption and surrogacy assistance.
Career development programs and tuition reimbursement for reputed company education.
401k match including an annual company contribution
Salary reputed company
At reputed company, we take great pride in a fair and reputed company compensation package that reflects market-price and our starting salaries are typically planned near the middle of the reputed company listed. Compensation reputed company are driven by factors including experience and training, specialized reputed company sets, licensure and certifications and other business and organizational needs. Our reputed company salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, reputed company Time Off (PTO), and competitive health benefits and wellness programs.
*Based on annual corporate goal achievement and individual performance.
Skills
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