Special Investigations Unit Manager – Audit, Clinical

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🔥 0 minutes ago

🐎 Kentucky, Louisiana, +3 more states – Remote

🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🌲 North Carolina – Remote 🎸 Mississippi – Remote 🌴 South Carolina – Remote

💵 $107.9k - $172.6k / year

⏰ Full Time

🟠 Senior

🔴 Lead

👔 Manager

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Blue Cross NC

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Blue Cross NC is a health insurance provider that offers a range of health plans and services to individuals and groups. The company focuses on delivering quality healthcare coverage and improving health outcomes for its members through innovative health programs and services. Blue Cross NC is committed to enhancing access to affordable healthcare while supporting the health and wellness of the communities it serves.

📋 Description

• Lead and support a high-performing team of clinicians and coders • Provide leadership, coaching, feedback, and professional development support for a remote workforce • Develop, monitor, and refine anti-fraud, waste, and abuse strategies with stakeholders • Ensure SIU activities comply with legal, regulatory, contractual, and company requirements • Identify opportunities to use AI and other tools to improve processes and efficiency • Incorporate clinical expertise into investigations and outlier detection analytics • Manage prepayment and post-payment medical record review workflows • Establish, monitor, and report team performance, production metrics, and goals • Advise team members on audit and clinical findings and peer reviews • Prepare the team for meetings with providers, regulators, legal counsel, and stakeholders • Build relationships with industry peers and contribute to tactical and strategic initiatives • Contribute to operational strategies and innovative audit and clinical oversight solutions • Monitor health care trends, industry developments, and government regulations • Recommend policy positions, initiatives, and program improvements • Collaborate with leaders managing vendor relationships • Lead or participate in internal committees, presentations, and cross-functional collaboration

🎯 Requirements

• Bachelor’s degree and 8+ years of relevant experience • In lieu of degree, 10+ years of experience in a related field • Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred • RN, PA, FNP, or other APN certification • For Behavioral Health specific roles, applicable licensures such as LMSW, LCSW, LPC, or LMFT will be considered • Experience leveraging data-driven insights to prioritize investigations and quantify financial impact • Data analytics, fraud detection modeling, and interpretation of complex healthcare claims data • Certified Professional Compliance Officer (CPCO) preferred/bonus • Certified Professional Coder (CPC) and other specialty certifications preferred/bonus • Statistics and extrapolation knowledge • Quality of Care Champion experience or knowledge • Authorization to work in the United States

🏖️ Benefits

• Work-life balance, flexibility, and autonomy • Medical, dental, and vision coverage • Health and wellness programs • Parental leave and support • Adoption and surrogacy assistance • Career development programs • Tuition reimbursement for continued education • 401k match including an annual company contribution • Annual Incentive Bonus • Paid Time Off (PTO) • Competitive health benefits and wellness programs • Remote work with a few in-office visits each year