Job Description

Responsibilities

• Oversee and manage the day-to-day operations and activities of the Fraud and Abuse Department, which is responsible for detecting, investigating, and mitigating potential fraud, waste, and abuse in the various the Funds benefits
• Directs the activities of the Fraud and Abuse Department and provides direct supervision to the Investigators, and provides mentoring, guidance, and productive feedback
• Oversees, reviews, and approves all investigative activity of the Fraud and Abuse Department's investigators, outside medical consultants, and contract investigators
• Develops strategy and sets standards on the design, development, and implementation of effective policies and procedures
• Implements and monitors fraud prevention and cost-savings strategies across the family of Funds, including implementing new technologies such as the STARSSentinel and CLEAR systems, and recommending new rules and edits to our benefits claims systems
• Monitors industry compliance issues and trends in order to advise the Director of Legal Operations on emerging or potential fraud, waste, and abuse issues across the family of Funds and their entities, while also recommending remediation plans
• Performs additional duties and projects as assigned

Qualifications

• Bachelor’s Degree in Business, Criminal Justice, or related field required; Master's Degree preferred
• Minimum of six (6) years of experience in the healthcare industry within a Special Investigations Unit (SIU) or equivalent governmental agency, and three (3) years of supervisory experience required
• Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Certified Economic Crime Forensic Examiner (CECFE), or Certified Insurance Fraud Investigator (CIFI0 highly preferred
• Proven track record in conducting and managing fraud investigations and/or remediating fraud, waste, and abuse risk in multiple lines of business or programs
• Proven leadership and management skills to include hiring, training, coaching, conflict resolution, performance management, and time management.