Healthcare SIU Manager

Company Overview:

Advance Your Career in Insurance Claims with Allied Universal® Compliance and Investigation Services. Allied Universal® Compliance and Investigation Services is the premier destination for a career in insurance claim investigation. As a global leader, we provide dynamic opportunities for claim investigators, SIU investigators, and surveillance investigators. Our team is committed to innovation and excellence, making a significant impact in the insurance industry.

If you're ready to grow with the best, explore a career with us and make a difference.

DUE TO OUR GROWTH - WE ARE LOOKING TO FILL THIS IMMEDIATELY.  CAN WORK REMOTE

Allied Universal® is hiring a Healthcare Special Investigations Unit Manager. The Healthcare Special Investigations Unit (SIU) Program Manager is responsible for the strategic oversight, operational leadership, and performance management of the Special Investigations Unit. This role supervises and directs investigative activities involving fraud, waste, and abuse (FWA) in government and commercial healthcare programs. The Healthcare Special Investigations Unit (SIU) Program Manager exercises independent judgment and discretion on matters of significance, including case strategy, regulatory interpretation, staffing decisions, risk mitigation, and external reporting to regulatory and law enforcement agencies.

This position supervises professional investigative staff and is accountable for operational effectiveness, regulatory compliance, and measurable financial recoveries and cost avoidance.

** RESPONSIBILITIES:*
* - Directly supervise, among others, SIU investigators, nurse auditors, documentation auditors, data analysts, and investigative support staff.

- Hire, train, evaluate, discipline, and terminate staff consistent with organizational policy.

- In partnership with other members of the senior leadership team establishes performance goals, productivity standards, and quality benchmarks.

- In partnership with other members of the leadership team and Human Resources Department develops succession planning and professional development pathways.

- Works effectively with the cross-functional team (Director, Sr. Director, Finance, Operations) manages departmental budgets, resource allocation, and vendor oversight.

- Provide strategic direction for complex FWA investigations involving providers, members, pharmacies, and ancillary entities.

- Review and approve investigative plans, case findings, referrals, and over payment calculations.

- Ensure timely and compliant referrals to state and federal agencies, including HHS-OIG, DOJ, and Medicaid Fraud Control Units (MFCUs).

- Ensure SIU operations comply with the contract requirements, including state and federal regulations and reporting.

- Interpret federal and state fraud statutes and guidance for operational implementation.

- Oversee reporting obligations, including annual fraud plans and regulatory submissions.

- Collaborate with Compliance, Legal, Provider Relations, Claims Operations, and Pharmacy teams.

- Support internal audits and external regulatory examinations.

- Present case outcomes and risk exposure to executive leadership. Exercises independent discretion in investigative strategy and regulatory interpretation.

- Coordinates the approval of high-risk case referrals and law enforcement escalations.

- Determines staffing structure and workload distribution.

- Works with plans, outside leaders and Directors and Sr. Directors to authorize over payment recoveries and civil action referrals within delegated authority.

- Responsible for department productivity and quality metrics.

** QUALIFICATIONS (MUST HAVE) :*
* + - Bachelor's degree required (Criminal Justice, Healthcare Administration, Nursing, Accounting, or related field) with at least eight (8) years of progressive healthcare fraud investigation and/or payment integrity experience or - Associate's degree required (Criminal Justice, Healthcare Administration, Nursing, Accounting, or related field) with at least ten (10) years of progressive healthcare fraud investigation and/or payment integrity experience and/or
- High School Diploma or Equivalent with at least…