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Sr. Manager, Major Case Investigative Unit (Medical & Provider Fraud)

Root Insurance Company -
Remote

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Job Details

$117,300 - $146,600 a year

Qualifications

Healthcare fraud investigations
Employee relationship building
Research
Suspicious activity investigations
Liability insurance knowledge
Healthcare billing investigations
Insurance investigations
Managing insurance claims teams
Cross-functional communication

Full Job Description

Root was founded on the belief that car insurance is broken, and we set out to change it. We’re harnessing the power of technology to revolutionize this archaic, complicated industry. Using machine learning and mobile telematic platforms, we’ve built one of the most innovative insurtech companies in the world.

The Opportunity

We are seeking a highly analytical and strategic Senior Manager - Major Case Investigative Unit to lead our fight against insurance fraud. In this newly created role, you will bridge the gap between First Party Medical (FPM) operations and the Special Investigative Unit (SIU). Your role will be to collaborate closely with SIU and FPM leadership to drive cross-functional projects and business solutions. Your primary mission will be to aggressively identify, investigate, and combat 1st and 3rd party medical fraud, with a specialized focus on complex provider fraud rings and schemes.

You will lead a specialized team of claims leaders, ensuring a balance of quality, efficiency, customer experience, and employee engagement. The ideal candidate brings deep technical expertise in high-risk jurisdictions (preferably NY, MI, NJ, FL) and a proven track record of developing leaders who can disrupt large-scale medical fraud operations.

Salary Range: $117,300 - $146,600 (Bonus & LTI Eligible)

Root is a “work where it works best” company. Meaning we will support you working in whatever location that works best for you across the US. We will continue to have our headquarters in Columbus, Ohio.

How You Will Make an Impact

Oversee the strategy and handling of complex cases that tend to involve multiple claims, parties, and schemes.
Direct projects and initiatives related specifically to major case and provider fraud initiatives.
Ensure leaders drive investigations that are conducted in a thorough, efficient manner that is completely compliant with laws, regulations, and ethics.
Monitor trends with lawsuit filings for FPM and Injury.
Manage defense spend per matter, taking specific venue nuances into consideration.
Lead and develop a collaborative team where everyone is engaged, empowered to express their ideas, and motivated to drive the organization forward through challenges.
Control inventory by ensuring proactive and efficient investigations that align with the established procedures.
Monitor results ensuring that medical bills are properly adjudicated and paid timely.
Engage in coaching appropriate behaviors with leaders, ensuring they are coaching effectively to drive performance, quality, and effective claim handling tactics.
Drive employee development, including both technical and leadership development.
Facilitate training and awareness sessions with claims teams to further develop their fraud awareness skills.
Ensure leaders monitor overall case quality through Quality Assurance reviews, Targeted Audits, and Closed File Reviews.
Ensure that customer claims are resolved in a professional and timely manner.
Maintain an environment where the importance of employee empowerment does not get lost in the day-to-day operations of running a claims department.
Recruits, retains and develops a highly motivated and accountable team of experienced and developing claim professionals
Lead teams investigating claims that are geographically dispersed across the country
Drive pace within the team, resulting in best-in-class LAE while maintaining high employee satisfaction.
Help establish and drive adherence to processes to drive technical claim handling, resulting in best-in-class loss performance while maintaining high customer satisfaction
Use internal controls associated with claims payments and quality of file handling
Advocates for talent and builds capabilities to ensure strong leadership and technical talent bench strength
Provides expertise to the team in reviewing, researching, investigating, negotiating, processing and adjusting claims

What You Will Need to Succeed

5+ years of progressive leadership experience in P&C Insurance, specifically overseeing First Party Medical (PIP/No-Fault) claims and/or Medical related Special Investigative Units (SIU).
Deep subject matter expertise in medical provider fraud, upcoding, unbundling, and complex multi-party clinic schemes.
Extensive experience managing medical claims and fraud investigations in New York, Michigan, New Jersey, and Florida (highly preferred).
Proven ability to manage and balance highly technical metrics, including cycle times, RTQA results, and closure rates.
Ability to identify broader fraud trends across organizations and build actionable defense strategies.
Bachelor’s degree or equivalent experience required
Strong technical understanding of liability and casualty principles
Experience managing complex, high exposure claim investigations through closure
Ability to build collaborative working relationships
Communicates and collaborates effectively in a virtual environment
High sense of professionalism while remaining empathetic
Curious in nature
Great attention to detail
Self-starter and ability to work independently and effectively prioritize work
Ability to handle ambiguity and quickly adapt when changes occur
Strong written and oral communication skills
Ability to approach problems with an open mind
Ability to obtain and maintain insurance licenses in several states (including Texas) within three months

As part of Root's interview process, we kindly ask that all candidates be on camera for virtual interviews. This helps us create a more personal and engaging experience for both you and our interviewers. Being on camera is a standard requirement for our process and part of how we assess fit and communication style, so we do require it to move forward with any applicant's candidacy. If you have any concerns, feel free to let us know once you are contacted. We’re happy to talk it through.

Consistent with the Americans with Disabilities Act (ADA) and the Civil Rights Act of 1964, it is the policy of Root to provide reasonable accommodation when requested by a qualified applicant or candidate with a disability, unless such accommodation would cause an undue hardship for Root. The policy regarding requests for reasonable accommodation applies to all aspects of the hiring process. If reasonable accommodation is needed, please contact [email protected]

Apply Now

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