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 comprehensive, efficient manner, fully compliant with laws, regulations, and ethical standards.

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

• Manage defense spending for each matter, considering specific venue nuances.

• Guide and nurture a collaborative team where all members feel engaged, empowered to share their ideas, and motivated to drive the organization forward through challenges.

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

• Monitor results to guarantee that medical bills are accurately adjudicated and paid in a timely fashion.

• Coach leaders on appropriate behaviors, ensuring they effectively guide their teams in enhancing performance, quality, and efficient claim handling tactics.

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

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

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

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

• Foster an environment where the significance of employee empowerment remains a priority amidst the daily operations of managing a claims department.

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

• Lead teams investigating claims that are spread across various geographic locations in the country.

• Promote efficiency within the team, resulting in best-in-class LAE while ensuring high employee satisfaction.

• Assist in establishing and promoting adherence to processes that enhance technical claim handling, leading to optimal loss performance while maintaining high customer satisfaction.

• Utilize internal controls related to claims payments and the quality of file management.

• Advocate for talent and build capabilities to ensure a robust leadership and technical talent pipeline.

• 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 knowledge 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 ability to manage and balance highly technical metrics, such as cycle times, RTQA results, and closure rates.

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

• Bachelor’s degree or equivalent experience is required.

• Strong technical understanding of liability and casualty principles.

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

• Ability to foster collaborative working relationships.

• High level of professionalism while maintaining empathy.

• Naturally curious.

• Exceptional attention to detail.

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

• Capacity to manage ambiguity and quickly adapt to changes.

• Strong written and verbal communication skills.

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

🏝️ Benefits

• Eligible for bonus and long-term incentives.

• Options for remote work.