Job Summary
This position manages SIU staff who are responsible for complaint or case investigations involving fraud, waste and abuse allegations which are moderate to complex. This position will involve oversight functions to ensure appropriate regulatory and compliance requirements are met and high-quality outcomes are achieved. Included in responsibilities are mentoring and development of SIU staff through training and other guidance opportunities. The candidate in this position will be expected to foster strong internal and external stakeholder relationships in a collaborative manner. This position may be required to maintain a limited investigative caseload.

Location Information: This role is primarily remote however is required to be able to commute onsite at our Corporate Headquarters as well as on-site visits to our FL based providers. Travel is required for this role. The preferred candidate will live within a commutable of our FL based offices.

What You Will Be Doing:

• Primarily manages staff who are responsible to complete complaint or case investigations regarding fraud, waste & abuse allegations. Position may be required to submit referrals to law enforcement, works with internal parties for administrative action, as well as assisting with claims data analysis to identify trends and schemes for case escalation.
• Plans, organizes, directs and controls all activities of assigned department(s). Identifies and manages risks, resolves conflicts and removes barriers that impede area's ability to achieve goals and performance expectations through discussion and guidance with upper management. Compiles and analyzes data required to understand trends and performance levels in inventory-related areas. Provides direction and training to employees using established policies and procedures, sets priorities for staff and ensure task completion. Identifies workload and/or resource balancing opportunities and recommends corrective actions. Manages human resource-related processes, including performance management, corrective action, time and attendance, etc.
• Contributes to business strategy by providing input on initiatives and projects to enhance efficiencies and processes. Leads/participates in staff meetings, team projects and team building sessions.
• Identifies potential high-risk areas for fraud and recommends improvements to internal controls, procedures, methods and/or medical guidelines.
• Position may be assigned an investigative caseload, and must Identify, investigate and evaluate complex to highly complex potential fraud, waste or abuse to determine valid cases for appropriate action; document findings, and prepares case referrals, letters, testify, etc. as applicable.
• May be required to provide testimony, consultant and/or offer education internally and externally to the organization.
• The essential functions listed represent the major duties of this role, additional duties may be assigned.

What You Must Have:

5+ years related work experience. Experience Details: healthcare fraud and investigation experience

2+ years direct supervisory/management experience
Related Bachelor's degree or additional related equivalent work experience

Strong knowledge of healthcare fraud trends/schemes and the investigation process.

Strong knowledge of medical review, auditing, and/or internal controls.

Strong knowledge of CPT, ICD-9/ICD-10 and HCPC codes.

Strong knowledge of medical cost management, claims, enrollment, and agent/agency data. Working knowledge of data analysis techniques.

Working knowledge of project management.

What We Would Preferred You Have:
Bachelor's degree in a related field

Designated as a CFE or AHFI or other recognized certification in a related field.

Experience providing deposition and/or court testimony.

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 includes employer contribution and employer match;
• Paid time off, volunteer time off, 10 holidays and two flexible Well-Being days
• Additional voluntary benefits available; and
• A comprehensive wellness program

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.

Typical Annualized Hiring Range: $80,800 - $92,000

Annualized Salary Range: $80,800 - $131,300


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 Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.