Resp & Qualifications
The Director, Special Investigation Unit is responsible for developing and executing organizational strategies for SIU and provides management oversight of the investigative team from the planning phase through the disposition of cases within the Special Investigations Unit. The Director ensures the team's investigative caseload is effectively and efficiently managed, as well as assigned and closed in a timely manner.
• Build the foundation of the CareFirst SIU which includes structure, select, and implement tools, develop processes, playbooks, and other infrastructure for the unit. Develop training materials and key metrics for both current incumbents and new hires
• Lead SIU comprised of SIU manager, supervisors and healthcare anti-fraud investigators spanning all plans and products in the corporation.
• Develop and implement a short term and long-term internal investigations strategy. Design and build out an internal anti-fraud process and team responsible for identifying and investigating suspicious financial and non-financial activity involving allegations of misconduct involving employees, agents, customers, and vendors.
• Day-to-Day leadership and management of the staff and caseloads is critical, therefore a disciplined approach to triage from Referrals and Validation in conjunction with internal and vendor data mining queries is essential
• Perform continuous reviews of anti-fraud programs and practices for investigations, statutory compliance, Unfair Claim practices, underwriting, premium audit, and loss prevention measures due to fraud.
• Lead the triage and case management process that maximizes recoveries while concurrently documenting all cases with criteria that enables high quality internal and external regulatory audit.
• Work closely with each divisional leader and the corporate compliance leadership, and other key operational and clinical staff to communicate potential fraud and abuse that may be taking place within the respective plans. Develop and execute plans in collaboration with the divisional leaders.
• Work closely with state and federal program integrity organizations, and the Medicaid Fraud Control Unit (MFCU), MEDIC, or other agencies in representing CareFirst.
• Ensure continued movement of cases from identification to referral, recovery or close.
• 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.
• Bachelor's degree
• 10+ years SIU and Specialized Handling leadership experience
• Excellent interpersonal skills, builds trust with associates, colleagues, and other stakeholders
• Exceeds at communicating and explaining concepts to others that are new or unfamiliar
• Empathetic with a passion to develop others, and solve problems,
• Ability to perform effectively across a range of levels from hands-on daily tasks to broader strategy and thinking about the bigger picture
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.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 12/6/2020
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship