Senior Manager Special Investigations

Job Summary

At HCSC, we are looking for a dynamic professional to join our Internal Investigations team. The role manages health‑care fraud and internal fraud investigations, trains investigators and support staff, maintains liaison with health‑care providers and law enforcement, and coordinates anti‑fraud activities across departments. The position collaborates with Compliance, Legal, Audit, Provider Services, Clinical Operations, and external regulatory agencies to detect, investigate, and mitigate fraudulent or abusive activities while ensuring compliance with federal and state healthcare regulations.

This hybrid/flex role requires on‑site presence three days per week and does not provide relocation or sponsorship.

• Design, implement, and optimize the pre‑payment review process to identify and prevent fraudulent, wasteful, abusive, or non‑compliant claims prior to payment.
• Oversee daily volume of claims and monitor program effectiveness through savings, cost avoidance, provider behavior changes, and regulatory compliance metrics.
• Work with internal stakeholders such as claims processing, legal, and provider network teams.
• Utilize claims data analysis, predictive analytics, and fraud detection tools to identify suspicious patterns and activities.
• Manage and develop a team of professional certified coders and investigative analysts.

• Bachelor’s Degree.
• At least 10 years of law enforcement or investigation experience, or healthcare fraud investigation experience.
• Minimum 3 years of management experience, including supervision of investigators and/or professional certified coders.
• Organizational and results‑oriented leadership skills.
• Experience in implementing a pre‑payment review process.
• Exceptional analytical, problem‑solving, and decision‑making abilities.
• Strong executive communication and presentation skills.
• Proficiency with MS Office Suite (Word, Excel, PowerPoint, Teams) and Workday.

• Certified Professional Coder (CPC) designation.
• Experience with WRIKE, a SaaS work‑management process platform.

HCSC offers a comprehensive rewards package that includes health and wellness benefits, a 401(k) savings plan with company match, a pension plan, paid time off, paid parental leave, disability and supplemental life insurance, an employee assistance program, paid holidays, tuition reimbursement, and additional incentives. Total compensation varies by role, experience, and location.

HCSC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristic.