Manager, Special Investigation Unit – SIU

This is a fully remote position, open to applicants in Arizona, +1 more state.

📋 Description

• Develop, execute, and oversee strategic initiatives to combat fraud, waste, and abuse while adhering to state and federal regulations and tracking relevant trends and schemes.

• Evaluate business processes and systems to ensure integrity and compliance in billing and claims payment.

• Lead a team to effectively investigate all potential fraud, waste, and abuse referrals.

• Create educational materials aimed at identifying waste activities as requested by the health plan and on an as-needed basis.

• Attend state and federal meetings as mandated by specific contracts.

• Review post-payment cases with relevant parties to facilitate refunds.

• Prepare and disseminate monthly and quarterly savings reports.

• Engage in Appeals Committee, work groups, and interdepartmental meetings.

⛳️ Requirements

• Bachelor’s degree in Business, Healthcare, Criminal Justice, or a related field, or equivalent experience.

• 4+ years of cumulative experience in medical claim investigation, financial impact analysis, business analysis, compliance, or fraud and abuse.

• Comprehensive understanding of medical terminology.

• Experience with Dental and Vision plans.

• Prior experience in a managed care environment and in a leadership or supervisory role, including hiring, training, task assignment, and performance management is preferred.

• Proficiency in Microsoft Excel, medical coding, claims processing, and data mining is preferred.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.