The Sr. Director, Special Investigations Unit is responsible for developing strategy and leading organization-wide programs for the prevention, detection, and referral for prosecution of fraud with respect to providers, members and employees. The Sr. Director will monitor and participate with national and regional information sharing groups with a focus on collecting data on emerging national trends or schemes to proactively anticipate risk and vulnerability for the Company. Additionally, the Sr. Director strategizes with Senior Leaders at many levels to strengthen overall fraud detection and prevention efforts. This position leads and manages the work of highly specialized staff and the position is responsible for developing and maintaining effective working relationships with external vendors, Blue Cross Blue Shield Association, and state and federal agencies.
The primary duties and responsibilities of the Special Investigation Unit include: • Provide channels where fraud can be reported • Analyze and evaluate complaints of potential fraud • Conduct fraud investigations • Develop corrective actions for issues identified, and ensure that corrective actions are implemented • Conduct pre-pay reviews of suspicious claims • Promote and provide fraud education and awareness to company employees, providers and members • Identify overpayments and initiate recoveries • Coordinate with and provide support to law enforcement and regulators • Comply with all state and federal regulatory requirements • Analyze risks of fraud through various inputs, including data analytics, and work with the organization to reduce the overall risk
We are an Equal Opportunity Employer/Protected Veteran/Disabled.
Job Requirements: • Bachelor's degree or equivalent work experience • 7+ years of experience with a combination of fraud, waste and abuse investigations, auditing, and compliance • 5+ years of management experience • Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) designation or equivalent certification • Broad knowledge of health care industry practices and applicable regulatory considerations • Excellent interpersonal and proven leadership skills with a demonstrated ability to establish relationships with senior executives across all multiple units • Proven skills at developing and maintaining effective working relationships with a variety of federal, state, and local law enforcement agencies or similar experience • Strong knowledge of government program requirements (i.e., Medicare, Medicaid) • Strong business-focused decision-making and problem solving skills • Proven ability to maintain confidentiality of all sensitive information • Knowledge of effective fraud, waste and abuse prevention and detection tactics, techniques, methods and processes.
Preferred: • Advanced degree in accounting, criminal justice, law or related field • License to practice law and/or Certified Public Accountant • Knowledge of state and federal laws and regulations relating to healthcare and prosecution of healthcare offenses.
Internal Number: 15007
About Florida Blue
Florida Blue is a subsidiary of a not-for-profit health solutions company dedicated to serving all Floridians in the pursuit of health.
Florida Blue is an independent licensee of the Blue Cross and Blue Shield Association, serving residents and businesses in the state of Florida.