CareFirst BlueCross BlueShield is the largest health care insurer in the Mid-Atlantic region. Every day, we help people make decisions that will positively impact their lives today and into the future. We invite you to take your experience to the next level in a company that is financially strong and nationally respected. The Special Investigation Director leads the Special Investigations Unit (SIU) in the identification, investigation, recovery, prosecution and prevention of fraudulent activities in accordance with state and federal requirements. This position is located in Owings Mills, MD.
Plans, schedules and manages the scope of investigations and monitoring, or as warranted, participates in the investigative activities
Collaborates with internal strategic business units, Medical Directs, Networks Management and Provider Relations, the Pharmacy Benefit Manager, industry partners, local, state and federal law enforcement agencies as well as national anti-fraud associations
Publicizes anti-fraud efforts through digital media, corporate presentations, intranet articles, posters, brochures, and ongoing training to raise the level of fraud, waste, and abuse awareness within CareFirst and the provider community
Reviews, edits, and approves reports prepared by investigative staff to ensure they are complete and well documented
Sets goals and objectives for the unit; achieves them by managing the SIU plan and budget
Interacts with providers and attorneys on case investigations and reports
Bachelor’s degree in business administration (accounting, finance), management sciences, nursing, criminal justice or relevant equivalent education
Minimum ten (10) years of experience in fraud and abuse investigations, health care fraud experience required with at least five (5) years of progressively increasing management responsibility leading to high-performing teams
At least one professional certification as a Certified Public Accountant (CPA), Certified Fraud Examiner (CFE), or Accredited Healthcare Fraud Investigator (AHFI)
Knowledge of investigatory best practices and methodologies and tools, including ability to manage investigation resources
Experience in evaluating claims using various forensic techniques and knowledge of related legal/regulatory issues
Demonstrated ability in developing and maintaining effective working relationships with a variety of federal, state, and local law enforcement agencies. Ability to communicate effectively, including but not limited to, annual SIU reporting to the Departments of Insurance (MIA, VBOI, DISB)
Must commit to frequent travel to multiple staff sites and CareFirst offices
Advanced degree in accounting, criminal justice, healthcare, law, or related field
We offer excellent benefits and a competitive salary. For complete job description and/or to apply online, please visit us at www.carefirst.com/careers and search our jobs database by Job ID 9569 EOE, M/F/D/V.
CareFirst BlueCross BlueShield is an independent licensee of the Blue Cross and Blue Shield Association.
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