Director, Special Investigations Unit, Regulatory Operations - Remote

Overview

The Director of the Special Investigations Unit (SIU) is responsible for overseeing operations, ensuring compliance, and managing investigations related to fraud, waste, and abuse in healthcare.

In Short

• Acts as a liaison between SIU operations and health plans.
• Coordinates with the AVP of SIU for development of antifraud plans.
• Responds to external audits and coordinates state readiness reviews.
• Develops audit tools based on regulatory requirements.
• Oversees vendor case management and ensures compliance.
• Identifies improvement opportunities through root cause analysis.
• Directs training for SIU personnel on protocols and investigative techniques.
• Engages staff in change management and business process transformation.
• Maintains knowledge of regulatory guidance through ongoing learning.
• Performs special projects as requested by leadership.

Requirements

• Bachelor's degree in a related field.
• 8-10 years relevant experience in special investigations or fraud prevention.
• Leadership experience required.
• Knowledge of payment integrity protocols.
• Excellent communication and organizational skills.
• Proficiency in Microsoft Office Suite.
• Knowledge of claims processing systems.
• Understanding of healthcare regulations.
• Strong decision making and critical thinking skills.
• Ability to work in a fast-paced environment.

Benefits

• Competitive benefits and compensation package.
• Equal Opportunity Employer (EOE).