AVP, Special Investigations Unit

Job Description

The AVP Special Investigations Unit (SIU) is responsible for overseeing and managing fraud, waste, and abuse (FWA) detection, investigation, and prevention efforts to safeguard the organization's assets and reduce healthcare costs. The role requires a vision to position the SIU with the right skill sets, cutting edge analytics tools, and robust processes to identify FWA schemes and direct investigations to resolve issues effectively and efficiently.

The AVP will develop strategies to create and maintain an organization that has the flexibility, knowledge, business acumen, and capacity to successfully address the dynamic space of FWA. This role involves leading a matrixed team of investigators, analysts, and clinical/coding subject matter experts, working closely with internal and external stakeholders and ensuring compliance with regulatory requirements. The AVP SIU also will coordinate closely within the Payment Integrity team to flag (i.e., pend, review) suspect providers and develop pre-and post-payment approaches to the challenges of FWA.

The AVP SIU requires externally facing credibility and leadership to collaborate with government regulators and the Blue Cross Blue Shield Association in connection with FWA investigation and reporting.

• Lead and mentor a team of fraud investigators, analysts, and other staff, providing guidance and support in fraud detection, prevention, and recovery efforts.
• Establish team goals, monitor performance, and ensure alignment with organizational objectives.
• Collaborate internally with other departments to create and maintain a seamless claims payment integrity program. Serve as liaison with key departments (Medical Management, Network Management, Data Analytics, Claims & Enrollment Operations) to develop, monitor, and update respective roles, responsibilities, and strategies related to claims payment integrity activities.

• Work closely with analytics teams to contribute to the development of fraud detection strategies using data analytics, machine learning, and other advanced techniques to identify patterns of fraudulent behavior.
• Conduct risk assessments to identify vulnerabilities in the organization's processes and implement measures to mitigate these risks. Design and manage proactive fraud prevention programs to minimize exposure to fraudulent activities.

• Oversee the management of the SIU’s intake and investigative procedures and coordinate with Payment Integrity’s prepayment analysts including workflow, productivity, accuracy, timeliness, and interaction with SIU and other Blue Cross NC staff members across the organization.
• Ensure timely and accurate reporting of investigation findings and coordinate with legal, healthcare, and data teams to take appropriate action.
• Collaborate with law enforcement agencies, regulatory bodies, and external partners during investigations.
• Prepare comprehensive reports summarizing investigation outcomes, risk assessments, and fraud trends.
• Liaison with Blue Cross NC Legal department on all SIU/Legal interactions including communications with provider attorneys and determinations in the pursuit of criminal and civil actions.

• Ensure all fraud investigation and prevention activities comply with state, federal, and industry regulations.
• Stay informed about changes in laws, regulations, and industry practices related to healthcare fraud.
• Assist in preparing documentation for audits, compliance reviews, and regulatory inquiries.
• As a critical component of the organization’s Compliance Program, support law enforcement in the prosecution of unlawful activity directed against corporate and customer assets. Establish and maintain working relationships with governmental law enforcement agencies.
• Lead the development and delivery of educational awareness and training programs for the organization as part of the annual Code of Conduct training.

• Strong leadership and team management ability
• Excellent communication and presentation skills.
• Ability to work cross-functionally with various teams and external partners.