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

This is a fully remote position, open to applicants in Florida, +3 more states.

📋 Description

• Supervise the strategy and management of intricate cases that typically involve multiple claims, parties, and schemes.

• Lead projects and initiatives specifically focused on major case and provider fraud efforts.

• Ensure that leaders conduct investigations in a thorough, efficient manner while fully complying with laws, regulations, and ethical standards.

• Track trends related to lawsuit filings for FPM and Injury.

• Oversee defense spending per case, taking into account specific venue nuances.

• Cultivate and guide a collaborative team environment where all members are engaged, encouraged to share their ideas, and motivated to advance the organization through challenges.

• Manage inventory by ensuring proactive and efficient investigations that adhere to established procedures.

• Monitor outcomes to ensure that medical bills are adjudicated correctly and paid in a timely fashion.

• Engage in coaching appropriate behaviors with leaders, ensuring effective coaching to enhance performance, quality, and effective claims handling tactics.

• Promote employee development, encompassing both technical and leadership growth.

• Conduct training and awareness sessions with claims teams to enhance their fraud awareness skills.

• Ensure leaders oversee overall case quality through Quality Assurance reviews, Targeted Audits, and Closed File Reviews.

• Guarantee that customer claims are resolved in a professional and timely manner.

• Maintain an environment where the significance of employee empowerment is recognized in the daily operations of the claims department.

• Recruit, retain, and develop a motivated and accountable team of experienced and developing claims professionals.

• Lead teams investigating claims that are spread geographically across the country.

• Foster a productive pace within the team, resulting in best-in-class Loss Adjustment Expense (LAE) while ensuring high employee satisfaction.

• Assist in establishing and promoting adherence to processes that enhance technical claims handling, leading to best-in-class loss performance while maintaining high customer satisfaction.

• Utilize internal controls associated with claims payments and the quality of file handling.

• Advocate for talent and develop capabilities to ensure a strong bench of leadership and technical talent.

• Provide expertise to the team in reviewing, researching, investigating, negotiating, processing, and adjusting claims.

⛳️ Requirements

• Over 5 years of progressive leadership experience in Property & Casualty Insurance.

• In-depth subject matter expertise in medical provider fraud, upcoding, unbundling, and complex multi-party clinic schemes.

• Extensive experience in managing medical claims and fraud investigations in New York, Michigan, New Jersey, and Florida.

• Proven capability to manage and balance highly technical metrics, including cycle times, RTQA results, and closure rates.

• Ability to identify broader fraud trends across organizations and develop actionable defense strategies.

• A bachelor’s degree or equivalent experience is required.

• Strong technical understanding of liability and casualty principles.

• Experience managing complex, high-exposure claim investigations to closure.

• Capability to build collaborative working relationships.

• High level of professionalism while remaining empathetic.

• Naturally curious.

• Excellent attention to detail.

• Self-starter with the ability to work independently and effectively prioritize tasks.

• Ability to handle ambiguity and quickly adapt to changes.

• Strong written and verbal communication skills.

• Ability to obtain and maintain insurance licenses in multiple states (including Texas) within three months.

🏝️ Benefits

• Eligible for bonuses and long-term incentives.

• Options for remote work.