Director, Special Investigations Unit

Job Description

What You'll Do

• Establishes and operationalizes SIU strategic plan that positions the SIU to successfully function in the continuously evolving changing health care arena;

• Leads an organization that effectively identifies sources of FWA, swiftly investigates actionable cases, and effectively creates resolutions that protect the company's assets;

• Oversees the SIU staff comprised of analysts, investigators, nurses, and data analytics personnel charged with the responsibility of preventing, detecting, investigating, and resolving suspected healthcare FWA, as well as seeking the prosecution of unlawful activity directed against corporate or customer assets.

• Oversees the management of the SIU's clinical staff including workflow management, productivity assessment, case findings accuracy and completeness, and interaction with other SIU and BCBSNC staff.

• Oversees the management of the SIU's intake and prepayment analysts including workflow, productivity, accuracy, timeliness and interaction with other SIU and BCBSNC staff.

• Liaisons with BCBSNC General Counsel's Office on all SIU-legal interactions including communications with provider attorneys and determinations on the pursuit of criminal and civil actions;

• Actively participates in regional and national networking entities and anti-fraud organizations, thereby obtaining valuable knowledge that could lead to actionable case analysis and cementing BCBSNC's position as a thought leader in the industry; and evaluates the landscape for latest FWA detection/resolution methodologies and advocates for their adoption.

• Collaborates internally with other departments to create a seamless claims payment integrity process. Serves as liaison with other key departments (Medical Management, Claims, and Network Management) to develop, monitor, and update respective roles and responsibilities and strategies related to claims payment integrity activities.

• Establishes and maintains working relationships with governmental law enforcement and regulatory agencies.

• Creates an environment that assures full compliance with all legal and regulatory mandates that impact the SIU, as a critical component of the organization's overall Compliance Program, as defined by federal and state regulators.

• Maintains a comprehensive understanding of emerging and current FWA trends and schemes through research, industry, and enforcement contacts and other sources.

• Assists in the development of fraud detection analytics, including a comprehensive analytics process that systematically evaluates claims submissions for fraudulent/abusive behavior. Assists staff in the development of pertinent queries and evaluation of data output to identify potential fraudulent/abusive schemes. Evaluates results from data analysis, internal and external referrals and all other complaints and tips to determine appropriate disposition. Thereafter, prioritizes and assigns matters for investigation and/or referral.

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

What You Bring

• Bachelor's degree in preferably in business administration, health care administration, finance, accounting, nursing or criminal justice.

• Minimum of 5 years supervisory experience.

• 10 years of investigative experience of which 3 years of that experience must be in one of the following areas:Law enforcement, a juris doctorate, fraud certification, medical coding certification, or a medical professional such as a doctor or registered nurse.

• Certified Fraud Examiner and/or Accredited Healthcare Fraud Investigator

Bonus Points

• Track record of measurable SIU performance improvement (e.g., increased recoveries/avoidance, reduced cycle times, improved hit rate) using KPI/OKR-driven operating rhythms.

• Experience implementing or optimizing SIU case management and intake triage tools (e.g., workflow rules, evidence management, audit trails) and translating business needs into effective tech requirements.

• Comfort with common healthcare data sources and analytic approaches (claims/encounters, eligibility, provider, pharmacy), including experience partnering with BI teams to build actionable dashboards and investigator-facing insights.

• Experience leading enterprise change or transformation work (new operating model, new workflows, new tools) with strong stakeholder management across Claims, Network, Medical Management, Compliance, and Finance.

• Experience with specialized fraud domains and investigative methods (e.g., pharmacy, behavioral health, DME, telehealth, DRG/inpatient, dental) including provider billing review and scheme development.

• Experience partnering with Payment Integrity functions (prepay/postpay, recovery, provider education) to translate SIU learnings into preventive controls and sustained savings.

• Advanced credentials and training beyond baseline requirements (e.g., CFE-AHI, CHC/CHPC, CPC/CCS, Six Sigma/Lean) and comfort with formal investigation standards and documentation.

• Experience overseeing anti-fraud vendor/delegated partner programs (e.g., PBM, Medicaid partner SIU, analytics vendors) including performance monitoring, issue remediation, and audit readiness.

What You'll Get

• The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community.

• Work-life balance, flexibility, and the autonomy to do great work.

• Medical, dental, and vision coverage along with numerous health and wellness programs.

• Parental leave and support plus adoption and surrogacy assistance.

• Career development programs and tuition reimbursement for continued education.

• 401k match including an annual company contribution

• Learn more

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

Skills

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