Senior Manager, Sales Investigations

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

📋 Description

• Acts as a senior leader and subject matter expert, mentoring and developing managers to cultivate a high-performing, compliance-oriented investigative team.

• Provides comprehensive leadership for the Sales Investigations Team (SIT), overseeing daily investigative operations.

• Manages the investigation of allegations of misconduct by Medicare Advantage agents and agencies, including sales-related violations, fraud, waste, and abuse (FWA) concerns received through hotline, regulatory, and special investigation channels.

• Offers strategic and operational guidance for the Sales Investigations Team (SIT) across the organization, including oversight of allegation intakes, regulatory-driven issues, and investigations concerning sales practices, agent/agency behavior, and associated FWA risks.

• Utilizes knowledge of Medicare Advantage sales distribution structures, including FDR relationships, captive agent employment agreements, and independent broker/agency contracts, to effectively scope, contextualize, and adjudicate allegations of misconduct.

• Establishes, maintains, and governs standards, protocols, and quality controls for investigations (case triage, scoping, investigative plans, interviews, documentation, evidence handling, chain-of-custody, and retention) to ensure cases endure regulatory, audit, and legal scrutiny.

• Sets standards for interpreting agent, agency, broker, and sales operations misconduct, including the identification and evaluation of new or emerging schemes; recommends enterprise posture, mitigations, and corrective actions.

• Utilizes data analysis and trend interpretation to identify systemic issues, provide evidence within investigations, and implement enterprise-level corrective action strategies that effectively reduce recurrence and mitigate compliance risks.

• Oversees and facilitates communication and coordination with external stakeholders as necessary, including CMS, state regulators, and law enforcement agencies; prepares and supports responses to regulatory inquiries, audits, and investigations.

• Governs investigation-related policy and program frameworks, including sales investigations operating procedures, any program integration, and compliance training requirements and content.

• Leads, coaches, and develops multi-layer teams, including SIT managers and investigators; fosters talent development, workload planning, and a culture of integrity, consistency, and continuous improvement.

• Ensures uniform application of investigative outcomes, including recommendations for disciplinary actions, contract actions, agent/agency remediation, corrective action plans, and control enhancements.

• Performs additional duties as assigned.

• Adheres to all policies and standards.

⛳️ Requirements

• Bachelor's Degree in Compliance, Law, Criminal Justice, or a related field; or equivalent experience is required.

• Master's Degree is preferred.

• Juris Doctor (JD) is preferred.

• A minimum of 6 years in Compliance, investigations, law enforcement leadership, SIU, FWA, audit, and/or regulatory functions within managed care, a healthcare payor, or a similarly regulated environment is required.

• At least 2 years of experience leading people leaders and/or multi-layer teams is preferred.

• Experience with Medicare Advantage sales distribution structures, including the relationships and contractual obligations among first-tier, downstream, and related entities (FDRs) is required.

• Experience with Medicare Advantage sales distribution models, including first-tier, downstream, and related entity (FDR) structures, captive agent employment arrangements, and independent broker/agency contracting is required.

• HCCA (CHC/CHPC), CFE, AHFI, CPCI, CPA, CIA, or other industry-related certification 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.