Florida Blue · 1 week ago
Sr Director Special Investigation Unit
Jacksonville, FL, United States
Full-time
Onsite
Senior Level, Lead/Staff
$136K/yr - $221K/yr
10+ years expFlorida Blue is a healthcare company focused on providing comprehensive services to its members. They are seeking a Sr. Director for the Special Investigation Unit to develop and implement strategies to prevent and detect fraud, waste, and abuse in collaboration with various stakeholders.
ConsultingHealth CareInsurance
Responsibilities
Develop and implement comprehensive strategies and high-level tactics to prevent and detect FWA involving providers, members, agents and other stakeholders
Create and execute business plans to drive FWA prevention and detection efforts, leveraging expertise to identify opportunities for policy improvement, reform, or creation
Collaborate with Senior Leaders across the organization to strengthen overall FWA detection and prevention efforts, considering new initiatives in response to regulatory, health benefit coverage, or technological changes
Collaborate closely with the Payment Integrity Office to identify and prioritize high-risk areas for FWA and develop joint strategies to address these risks
Prepare and present updates and reports to the Audit, Risk and Compliance Committee and Corporate Ethics and Compliance Committee on SIU activities, including risks, new and emerging schemes, performance metrics and case results
Collaborate with internal stakeholders to identify opportunities to integrate artificial intelligence and machine learning into SIU workflows, enhancing investigative capabilities and improving FWA detection and prevention efforts
Develop and maintain a proactive approach to detecting FWA, building cases for investigation and prosecution as needed. Oversee multiple FWA data mining and analysis projects, investigations, and initiatives, ensuring compliance with federal and state regulations
Represent the Company in various forums, including depositions, testimony, and intelligence sharing sessions in support of FWA actions
Participate in provider disputes, settlement negotiations, arbitrations, administrative hearings, and criminal proceedings, as required
Develop and maintain effective relationships with internal and external stakeholders to combat FWA
Collaborate with the compliance department to share status updates and referrals to the MEDIC, CMS and other regulatory agencies; participate in regulatory examinations, as needed
Work closely with Legal Affairs on litigation matters, ensuring effective coordination and support
Develop and maintain leadership positions in national organizations, such as the National Health Care Anti-Fraud Association and BCBSA, to stay informed about industry trends and best practices
Manage and maintain effective relationships with external data mining vendors, ensuring high-quality services and effective collaboration
Develop employee training to raise the level of FWA awareness
Provide FWA awareness presentations to internal departments, external entities and customers
Provide leadership and direction to the SIU, overseeing the detection, investigation, and disposition of FWA cases
Manage a team of employees across multiple offices, ensuring effective coordination and collaboration
Set clear goals and objectives for the SIU, aligning with organizational priorities and strategic objectives
Develop and manage the SIU's operating plan and budget, ensuring alignment with organizational goals and objectives, strategic priorities, and resource allocations
Qualification
Required
10+ years' related work experience - combination of fraud investigations, auditing, data analysis and compliance
Broad knowledge of health care industry practices and applicable regulatory requirements
Strong knowledge of government program requirements (e.g., Medicare, Affordable Care Act)
3+ years' direct supervisory/management experience
Related bachelor's degree or additional equivalent work experience
Extensive knowledge of fraud and auditing concepts and strong investigatory skills
Excellent interpersonal and proven leadership skills with a demonstrated ability to establish relationships with senior executives across all business units
Proven skills at developing and maintaining effective working relationships with a variety of federal, state, and local law enforcement agencies or similar experience
Preferred
Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) designation
Master's degree or higher in accounting, business, criminal justice, law or related field
CPA – Certified Public Accountant
Knowledge of state and federal laws and regulations relating to healthcare and prosecution of healthcare offenses
Benefits
Medical, dental, vision, life and global travel health insurance
Income protection benefits: life insurance, short- and long-term disability programs
Leave programs to support personal circumstances
Retirement Savings Plan including employer match
Paid time off, volunteer time off, 10 holidays and 2 well-being days
Additional voluntary benefits available
A comprehensive wellness program
Company
Florida Blue
Florida Blue is a subsidiary of a not-for-profit health solutions company dedicated to serving all Floridians in the pursuit of health.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Patrick Geraghty
President and CEO
Recent News
2025-11-04
Company data provided by crunchbase