Apply on Employer Site

Blue Cross NC · 1 day ago

AVP, Special Investigations Unit

United States

Full-time

Remote

Mid, Senior Level

$191K/yr - $306K/yr

7+ years exp

Blue Cross NC is a healthcare organization focused on managing fraud, waste, and abuse detection and prevention. The AVP of the Special Investigations Unit will lead a team in developing strategies and overseeing investigations to safeguard organizational assets and ensure compliance with regulations.

Financial ServicesHealth InsuranceInsurance

Comp. & Benefits

Responsibilities

Lead and mentor a team of fraud investigators, analysts, and other staff, providing guidance and support in fraud detection, prevention, and recovery efforts

Establish team goals, monitor performance, and ensure alignment with organizational objectives

Collaborate internally with other departments to create and maintain a seamless claims payment integrity program. Serve as liaison with other key departments (Medical Management, Network Management, Data Analytics, Claims & Enrollment Operations) to develop, monitor, and update respective roles, responsibilities, and strategies related to claims payment integrity activities

Work closely with analytics teams to contribute to the development of fraud detection strategies using data analytics, machine learning, and other advanced techniques to identify patterns of fraudulent behavior

Conduct risk assessments to identify vulnerabilities in the organization’s processes and implement measures to mitigate these risks. Design and manage proactive fraud prevention programs to minimize exposure to fraudulent activities

Oversee the management of the SIU’s intake and investigative procedures and coordinate with Payment Integrity’s prepayment analysts including workflow, productivity, accuracy, timeliness, and interaction with SIU and other Blue Cross NC staff members across the organization

Ensure timely and accurate reporting of investigation findings and coordinate with legal, healthcare, and data teams to take appropriate action

Collaborate with law enforcement agencies, regulatory bodies, and external partners during investigations

Prepare comprehensive reports summarizing investigation outcomes, risk assessments, and fraud trends

Liaison with Blue Cross NC Legal department on all SIU/Legal interactions including communications with provider attorneys and determinations in the pursuit of criminal and civil actions

Ensure all fraud investigation and prevention activities comply with state, federal, and industry regulations

Stay informed about changes in laws, regulations, and industry practices related to healthcare fraud

Assist in preparing documentation for audits, compliance reviews, and regulatory inquiries

As a critical component of the organization’s Compliance Program, support law enforcement in the prosecution of unlawful activity directed against corporate and customer assets. Establish and maintain working relationships with governmental law enforcement agencies

Lead the development and delivery of educational awareness and training programs for the organization as part of the annual Code of Conduct training

Qualification

Healthcare fraud detectionData analyticsLeadership experienceRegulatory complianceFraud investigationRisk assessmentHealthcare systems knowledgeRelevant certificationsCommunication skillsTeam managementCross-functional collaborationPresentation skills

Required

Minimum 7+ years of experience in healthcare fraud detection, investigation, or auditing

Bachelor's degree preferred in healthcare administration, finance, criminal justice, or related field/specialized training/relevant professional qualification

In-depth knowledge of healthcare systems claims processing, coding/reimbursement, and regulatory requirements related to healthcare fraud

Minimum 5+ years in a leadership role

Strong leadership and team management ability

Excellent communication and presentation skills

Ability to work cross-functionally with various teams and external partners