Senior Manager – Special Investigations

Role Overview

• Manage health care fraud and internal fraud investigations
• Manage and train investigators and support staff
• Establish and maintain liaison with health care providers and law enforcement
• Coordinate anti-fraud activities with other departments at HCSC
• Partner with Compliance, Legal, Audit, Provider Services, Clinical Operations, and external regulatory agencies to detect, investigate, and mitigate fraudulent or abusive activities
• Ensure compliance with federal and state healthcare regulations
• Lead design, implementation, and ongoing optimization of pre-payment review process
• Oversee daily volume of claims and monitor program effectiveness through savings, cost avoidance, provider behavior changes, and regulatory compliance metrics
• 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

Requirements

• Bachelor’s Degree
• 10 years law enforcement/investigation experience or healthcare fraud investigation experience
• 3 years management experience, including supervision of investigators and/or professional certified coders
• Organizational skills, results oriented with demonstrated leadership skills
• Experience in the implementation of pre-payment review process
• Exceptional analytical, problem-solving, and decision-making abilities
• Strong executive communication and presentation skills
• PC proficiency to include the MS Office Suite (Word, Excel, PowerPoint, Teams) as well as Workday
• Preferred: Certified Professional Coder (CPC) designation
• Preferred: Experience with WRIKE (SaaS work management process platform)

Benefits

• Health and wellness benefits
• 401(k) savings plan
• Pension plan
• Paid time off
• Paid parental leave
• Disability insurance
• Supplemental life insurance
• Employee assistance program
• Paid holidays
• Tuition reimbursement
• Other incentives