Program Manager III – SIU Intelligence, Innovation

This is a fully remote position, open to applicants in New York.

📋 Description

• Assist in the strategic planning, development, and implementation of proactive anti-fraud detection initiatives, tools, and analytics programs for SIU.

• Convert extensive and intricate data sets into defensible, actionable analytical insights that support investigative lead generation, case development, fraud prevention, and data-driven decision-making.

• Utilize HCFS PostShield, AI Shield, Pharmacy Shield, and other internal and external data resources to pinpoint emerging risks and formulate detection strategies.

• Collaborate with SIU leadership and enterprise stakeholders to design and execute analytical methodologies, predictive monitoring solutions, dashboards, performance metrics, and reporting functionalities.

• Work in partnership with SIU, Claims, Configuration, IT, Clinical, Compliance, Market Operations, and external partners.

• Investigate, assess, and track new fraud schemes, industry trends, regulatory changes, and analytical prospects.

• Present analytical findings, fraud trends, program performance, financial impacts, risks, and strategic recommendations to senior leadership and stakeholders.

• Ensure maintenance of audit-ready documentation, including program roadmaps, governance artifacts, risk and decision logs, methodology documentation, claim volume analyses, performance metrics, and financial impact reports.

• Execute other responsibilities as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• A Bachelor's Degree in Business Administration, Healthcare Administration, or a related field, or four (4) years of equivalent professional experience is required.

• A minimum of 5 years of experience in program, project, or product management is required.

• Preferred experience in healthcare fraud, analytics, investigations, project management, data science, or related healthcare environments.

• Preferred certifications include CFE, AHFI, CHC, PMP, SAS, CPC.

• Must comply with enterprise governance standards, regulatory requirements, policies, and standards.

• Qualified candidates with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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

• Additional forms of incentives may be included in total compensation.

• Equal opportunity employer committed to diversity.