Senior Manager, Major Case Investigative Unit – Medical & Provider Fraud

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🔥 12 minutes ago

🐊 Florida, New Jersey, +2 more states – Remote

🐊 Florida – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🚗 Michigan – Remote

💵 $117.3k - $146.6k / year

⏰ Full Time

🟠 Senior

👔 Manager

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Root Insurance Agency

WebsiteLinkedInAll Job Openings

1 - 10 employees

📋 Description

• Oversee the strategy and handling of complex cases that tend to involve multiple claims, parties, and schemes • Direct projects and initiatives related specifically to major case and provider fraud initiatives • Ensure leaders drive investigations that are conducted in a thorough, efficient manner that is completely compliant with laws, regulations, and ethics • Monitor trends with lawsuit filings for FPM and Injury • Manage defense spend per matter, taking specific venue nuances into consideration • Lead and develop a collaborative team where everyone is engaged, empowered to express their ideas, and motivated to drive the organization forward through challenges • Control inventory by ensuring proactive and efficient investigations that align with the established procedures • Monitor results ensuring that medical bills are properly adjudicated and paid timely • Engage in coaching appropriate behaviors with leaders, ensuring they are coaching effectively to drive performance, quality, and effective claim handling tactics • Drive employee development, including both technical and leadership development • Facilitate training and awareness sessions with claims teams to further develop their fraud awareness skills • Ensure leaders monitor overall case quality through Quality Assurance reviews, Targeted Audits, and Closed File Reviews • Ensure that customer claims are resolved in a professional and timely manner • Maintain an environment where the importance of employee empowerment does not get lost in the day-to-day operations of running a claims department • Recruits, retains and develops a highly motivated and accountable team of experienced and developing claim professionals • Lead teams investigating claims that are geographically dispersed across the country • Drive pace within the team, resulting in best-in-class LAE while maintaining high employee satisfaction • Help establish and drive adherence to processes to drive technical claim handling, resulting in best-in-class loss performance while maintaining high customer satisfaction • Use internal controls associated with claims payments and quality of file handling • Advocates for talent and builds capabilities to ensure strong leadership and technical talent bench strength • Provides expertise to the team in reviewing, researching, investigating, negotiating, processing and adjusting claims

🎯 Requirements

• 5+ years of progressive leadership experience in P&C Insurance • Deep subject matter expertise in medical provider fraud, upcoding, unbundling, and complex multi-party clinic schemes • Extensive experience managing medical claims and fraud investigations in New York, Michigan, New Jersey, and Florida • Proven ability to manage and balance highly technical metrics, including cycle times, RTQA results, and closure rates • Ability to identify broader fraud trends across organizations and build actionable defense strategies • Bachelor’s degree or equivalent experience required • Strong technical understanding of liability and casualty principles • Experience managing complex, high exposure claim investigations through closure • Ability to build collaborative working relationships • High sense of professionalism while remaining empathetic • Curious in nature • Great attention to detail • Self-starter and ability to work independently and effectively prioritize work • Ability to handle ambiguity and quickly adapt when changes occur • Strong written and oral communication skills • Ability to obtain and maintain insurance licenses in several states (including Texas) within three months.

🏖️ Benefits

• Bonus & LTI Eligible • Remote work options