Senior Manager, Special Investigation Unit (SIU) - Premera Blue Cross
Mountlake Terrace, WA
About the Job
Join Our Team: Do Meaningful Work and Improve People’s Lives
Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.
To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives! As a result of these efforts we are proud to share that Forbes ranked Premera among America’s 2023 Best Midsize Employers (https://www.forbes.com/lists/best-midsize-employers/?sh=58210f5e210f) and America's 2023 Best Employers By State (https://www.forbes.com/lists/best-employers-by-state/?sh=21c7c3d1983b) .
Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com .
As a Senior Manager of the Special Investigation Unit (SIU) , you will lead a team of Investigators to detect, investigate, remediate, and refer to law enforcement as appropriate incidents of fraud, waste, and abuse (FWA) arising in connection with medical, behavioral, dental, and other healthcare services. You will design and lead cross-functional initiatives, building Premera’s medical and pharmacy anti-FWA efforts in collaboration with Payment Integrity, Operations, Legal, Clinical, and IT teams, and will leverage your own experience and industry-standard practices to help Premera benchmark its FWA activities, and demonstrate innovation and creativity in working to exceed these benchmarks.
This is an onsite/hybrid role, with onsite days required. You must live within driving distance of our Mountlake Terrace campus, located about 15 miles north of Seattle, Washington.
What you’ll do:
+ Lead Premera’s Special Investigations Unit in driving the development, implementation, and communication of fraud prevention, detection, investigation, reporting, and recovery strategies designed to support organizational goals and objectives.
+ Directly supervise SIU staff, including hiring, directing, planning work, managing performance, and professional development.
+ Maintain oversight of and consistency in the deployment of the Company’s internal and external fraud awareness training and communication programs. Chair the SIU Steering Committee.
+ Maintain an awareness of applicable statutory laws, regulations, and judicial developments, and in conjunction with Premera’s internal legal counsel, assure the Company’s compliance with applicable legal, regulatory, and contract anti-fraud requirements.
+ Leverage partnerships with other business units and departments to develop, implement, and enhance enterprise-wide approaches to fraud detection and prevention.
+ Manage the day-to-day department performance including case assignments, case development, case review, overpayment recoveries, law enforcement referrals, training of staff, and coordination with other departments.
+ Establish and regularly report metrics for the SIU. Report on SIU activities and performance to appropriate management committees.
+ Lead team in investigations and monitor investigation quality by providing technical assistance in case development, serving as the Company's representative during formal proceedings when necessary and reviewing and approving dispositions of cases.
+ Direct the creation, modification, and implementation of policies, procedures, methods, and systems required for the prevention, detection, and investigation of fraud and abuse, including evaluating business technology requirements and recommending viable tech solutions, modifications, and/or enhancements to support anti-fraud efforts.
+ Lead team in communication and training sessions for providers when appropriate.
+ Foster and maintain positive relationships and coordination with representatives of the Company core functions, policyholders, law enforcement, other Blue Cross Blue Shield Plans, other commercial health plans, and the general public.
+ Responsible for the database system; maintain, monitor, and analyze operating results and report results to leadership.
+ Plan/forecast for SIU to meet future business needs, including commercial and government program lines of business.
+ As part of this role, you may be assigned internal controls derived from Premera’s internal controls framework. You will be accountable for understanding the controls assigned to you, their impacts on Premera, and to ensure that they are operating effectively.
+ As part of this role, you may have responsibility for the oversight of third parties. You will be accountable for ensuring the third parties assigned to you operate effectively, in compliance with their contract and Premera’s Third Party Code of Conduct, and that you and the third parties complete all assigned mitigation activities in a timely and accurate manner.
What you’ll bring:
+ Bachelor’s Degree in Accounting, Finance, Management, Nursing, Criminal Justice, or similar field of study. (Required)
+ (8) years of experience with anti-fraud with specific experience involving healthcare fraud, including a minimum of (3) years of related SIU/criminal management experience with healthcare investigations. (Required)
+ Master’s Degree in Accounting, Finance, Management, Nursing, Criminal Justice, or similar field of study preferred.
+ Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred.
+ Certified Public Accountant (CPA) or Registered Nurse (RN) preferred.
+ Experience creating and implementing a healthcare anti-fraud program.
+ Knowledge of healthcare claims and anti-fraud software tools.
+ Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions.
+ Proven ability to communicate complex subjects to all levels of employees, management, and external contacts.
+ Excellent communication and negotiation skills, as well as the capability of taking the lead in interviews with suspects and/or their attorneys.
+ Strong technical writing skills demonstrating the ability to write reports and business correspondence and to prepare case files.
+ In-depth knowledge of the insurance industry, Special Investigation Unit operations, claims handling and payment operations, and insurance contracts.
+ Ability to interact with others in one-on-one situations to identify issues/problems and provide training/coaching to correct problem areas.
+ Strong problem-solving skills and decision-making abilities.
+ Organizational and team building skills.
What we offer
+ Medical, vision and dental coverage
+ Life and disability insurance
+ Retirement programs (401K employer match and pension plan)
+ Wellness incentives, onsite services, a discount program and more
+ Tuition assistance for undergraduate and graduate degrees
+ Generous Paid Time Off to reenergize
+ Free parking
Equal employment opportunity/affirmative action:
Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.
If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.
Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin _._
The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.
National Plus Salary Range:
$128,700.00 - $218,800.00
_*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska_ _._
At Premera, we make healthcare work better. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives.
As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services.
Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.
Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.
To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives! As a result of these efforts we are proud to share that Forbes ranked Premera among America’s 2023 Best Midsize Employers (https://www.forbes.com/lists/best-midsize-employers/?sh=58210f5e210f) and America's 2023 Best Employers By State (https://www.forbes.com/lists/best-employers-by-state/?sh=21c7c3d1983b) .
Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com .
As a Senior Manager of the Special Investigation Unit (SIU) , you will lead a team of Investigators to detect, investigate, remediate, and refer to law enforcement as appropriate incidents of fraud, waste, and abuse (FWA) arising in connection with medical, behavioral, dental, and other healthcare services. You will design and lead cross-functional initiatives, building Premera’s medical and pharmacy anti-FWA efforts in collaboration with Payment Integrity, Operations, Legal, Clinical, and IT teams, and will leverage your own experience and industry-standard practices to help Premera benchmark its FWA activities, and demonstrate innovation and creativity in working to exceed these benchmarks.
This is an onsite/hybrid role, with onsite days required. You must live within driving distance of our Mountlake Terrace campus, located about 15 miles north of Seattle, Washington.
What you’ll do:
+ Lead Premera’s Special Investigations Unit in driving the development, implementation, and communication of fraud prevention, detection, investigation, reporting, and recovery strategies designed to support organizational goals and objectives.
+ Directly supervise SIU staff, including hiring, directing, planning work, managing performance, and professional development.
+ Maintain oversight of and consistency in the deployment of the Company’s internal and external fraud awareness training and communication programs. Chair the SIU Steering Committee.
+ Maintain an awareness of applicable statutory laws, regulations, and judicial developments, and in conjunction with Premera’s internal legal counsel, assure the Company’s compliance with applicable legal, regulatory, and contract anti-fraud requirements.
+ Leverage partnerships with other business units and departments to develop, implement, and enhance enterprise-wide approaches to fraud detection and prevention.
+ Manage the day-to-day department performance including case assignments, case development, case review, overpayment recoveries, law enforcement referrals, training of staff, and coordination with other departments.
+ Establish and regularly report metrics for the SIU. Report on SIU activities and performance to appropriate management committees.
+ Lead team in investigations and monitor investigation quality by providing technical assistance in case development, serving as the Company's representative during formal proceedings when necessary and reviewing and approving dispositions of cases.
+ Direct the creation, modification, and implementation of policies, procedures, methods, and systems required for the prevention, detection, and investigation of fraud and abuse, including evaluating business technology requirements and recommending viable tech solutions, modifications, and/or enhancements to support anti-fraud efforts.
+ Lead team in communication and training sessions for providers when appropriate.
+ Foster and maintain positive relationships and coordination with representatives of the Company core functions, policyholders, law enforcement, other Blue Cross Blue Shield Plans, other commercial health plans, and the general public.
+ Responsible for the database system; maintain, monitor, and analyze operating results and report results to leadership.
+ Plan/forecast for SIU to meet future business needs, including commercial and government program lines of business.
+ As part of this role, you may be assigned internal controls derived from Premera’s internal controls framework. You will be accountable for understanding the controls assigned to you, their impacts on Premera, and to ensure that they are operating effectively.
+ As part of this role, you may have responsibility for the oversight of third parties. You will be accountable for ensuring the third parties assigned to you operate effectively, in compliance with their contract and Premera’s Third Party Code of Conduct, and that you and the third parties complete all assigned mitigation activities in a timely and accurate manner.
What you’ll bring:
+ Bachelor’s Degree in Accounting, Finance, Management, Nursing, Criminal Justice, or similar field of study. (Required)
+ (8) years of experience with anti-fraud with specific experience involving healthcare fraud, including a minimum of (3) years of related SIU/criminal management experience with healthcare investigations. (Required)
+ Master’s Degree in Accounting, Finance, Management, Nursing, Criminal Justice, or similar field of study preferred.
+ Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred.
+ Certified Public Accountant (CPA) or Registered Nurse (RN) preferred.
+ Experience creating and implementing a healthcare anti-fraud program.
+ Knowledge of healthcare claims and anti-fraud software tools.
+ Possess comprehensive knowledge of fraud investigative procedures and judicial processes relating to fraud prosecutions.
+ Proven ability to communicate complex subjects to all levels of employees, management, and external contacts.
+ Excellent communication and negotiation skills, as well as the capability of taking the lead in interviews with suspects and/or their attorneys.
+ Strong technical writing skills demonstrating the ability to write reports and business correspondence and to prepare case files.
+ In-depth knowledge of the insurance industry, Special Investigation Unit operations, claims handling and payment operations, and insurance contracts.
+ Ability to interact with others in one-on-one situations to identify issues/problems and provide training/coaching to correct problem areas.
+ Strong problem-solving skills and decision-making abilities.
+ Organizational and team building skills.
What we offer
+ Medical, vision and dental coverage
+ Life and disability insurance
+ Retirement programs (401K employer match and pension plan)
+ Wellness incentives, onsite services, a discount program and more
+ Tuition assistance for undergraduate and graduate degrees
+ Generous Paid Time Off to reenergize
+ Free parking
Equal employment opportunity/affirmative action:
Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.
If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.
Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin _._
The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.
National Plus Salary Range:
$128,700.00 - $218,800.00
_*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska_ _._
At Premera, we make healthcare work better. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives.
As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services.
Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.
Source : Premera Blue Cross
