Job Summary
The Sr. Director, Special Investigation Unit (SIU) is responsible for developing and implementing organization-wide strategies to prevent, detect, and refer for prosecution fraud, waste and abuse (FWA) involving providers, members, agents, and other stakeholders. Key responsibilities include: (i) monitoring and participating in national and regional information-sharing groups to stay informed about emerging trends and schemes and proactively identifying potential risks and vulnerabilities for the Company; (ii) collaborating with Senior Leaders across the organization to enhance FWA detection and prevention efforts; and (iii) leading a team of highly specialized staff and fostering effective working relationships with vendors, the Blue Cross Blue Shield Association (BCBSA), and state and federal agencies.
Key Responsibilities:
Strategic Leadership:
• Develop and implement comprehensive strategies and high-level tactics to prevent and detect FWA involving providers, members, agents and other stakeholders.
• Create and execute business plans to drive FWA prevention and detection efforts, leveraging expertise to identify opportunities for policy improvement, reform, or creation.
• Collaborate with Senior Leaders across the organization to strengthen overall FWA detection and prevention efforts, considering new initiatives in response to regulatory, health benefit coverage, or technological changes.
• Collaborate closely with the Payment Integrity Office to identify and prioritize high-risk areas for FWA and develop joint strategies to address these risks.
• Prepare and present updates and reports to the Audit, Risk and Compliance Committee and Corporate Ethics and Compliance Committee on SIU activities, including risks, new and emerging schemes, performance metrics and case results.
Investigations and Data Analysis:
• Collaborate with internal stakeholders to identify opportunities to integrate artificial intelligence and machine learning into SIU workflows, enhancing investigative capabilities and improving FWA detection and prevention efforts.
• Develop and maintain a proactive approach to detecting FWA, building cases for investigation and prosecution as needed. Oversee multiple FWA data mining and analysis projects, investigations, and initiatives, ensuring compliance with federal and state regulations.
External Representation:
• Represent the Company in various forums, including depositions, testimony, and intelligence sharing sessions in support of FWA actions.
• Participate in provider disputes, settlement negotiations, arbitrations, administrative hearings, and criminal proceedings, as required.
Collaboration and Stakeholder Engagement
• Develop and maintain effective relationships with internal and external stakeholders to combat FWA.
• Collaborate with the compliance department to share status updates and referrals to the MEDIC, CMS and other regulatory agencies; participate in regulatory examinations, as needed.
• Work closely with Legal Affairs on litigation matters, ensuring effective coordination and support.
• Develop and maintain leadership positions in national organizations, such as the National Health Care Anti-Fraud Association and BCBSA, to stay informed about industry trends and best practices.
Vendor Management
• Manage and maintain effective relationships with external data mining vendors, ensuring high-quality services and effective collaboration.
Implement FWA awareness program
• Develop employee training to raise the level of FWA awareness.
• Provide FWA awareness presentations to internal departments, external entities and customers.
Leadership and Talent Development
• Provide leadership and direction to the SIU, overseeing the detection, investigation, and disposition of FWA cases.
• Manage a team of employees across multiple offices, ensuring effective coordination and collaboration.
• Set clear goals and objectives for the SIU, aligning with organizational priorities and strategic objectives.
Financial Management and Planning
• Develop and manage the SIU's operating plan and budget, ensuring alignment with organizational goals and objectives, strategic priorities, and resource allocations.
Required:
• 10+ years' related work experience - combination of fraud investigations, auditing, data analysis and compliance.
• Broad knowledge of health care industry practices and applicable regulatory requirements.
• Strong knowledge of government program requirements (e.g., Medicare, Affordable Care Act).
• 3+ years’ direct supervisory/management experience.
• Related bachelor's degree or additional equivalent work experience.
• Extensive knowledge of fraud and auditing concepts and strong investigatory skills.
• Excellent interpersonal and proven leadership skills with a demonstrated ability to establish relationships with senior executives across all business units.
• Proven skills at developing and maintaining effective working relationships with a variety of federal, state, and local law enforcement agencies or similar experience.
Preferred:
• Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) designation
• Master’s degree or higher in accounting, business, criminal justice, law or related field
• CPA – Certified Public Accountant
• Knowledge of state and federal laws and regulations relating to healthcare and prosecution of healthcare offenses.
General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally
What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.
To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
- Medical, dental, vision, life and global travel health insurance;
- Income protection benefits: life insurance, short- and long-term disability programs;
- Leave programs to support personal circumstances;
- Retirement Savings Plan including employer match;
- Paid time off, volunteer time off, 10 holidays and 2 well-being days;
- Additional voluntary benefits available; and
A comprehensive wellness program
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Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.
Annualized Salary Range: $136,000 - $221,000
Typical Annualized Hiring Range: $136,000 - $170,000
Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.
We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.
