Job Description Summary:

The role is responsible for developing, executing, and overseeing a comprehensive anti-fraud program driven by advanced data analytics and focused on identifying, investigating and mitigating fraud, waste and abuse across all lines of business. This position plans and directs activities related to program strategy, coordination, investigation, and reporting of fraud, waste, and abuse. This position ensures timely, thorough, and well-documented investigations; and drives continuous improvement through monitoring of trends, root-cause analysis, and corrective action. The role also establishes standards, procedures, and oversight mechanisms to support consistent case management, reporting, and outcome measurements across the enterprise.

Responsibilities include but are not limited to:

• Supervises the detection, investigation, reporting and mitigation of fraud, waste and abuse across all lines of business. Oversees the development and the implementation of an enterprise anti-fraud program including intake, triage, investigation, recovery, and referral processes, informed by advanced data analytics. Establishes and oversees standards, policies, and procedural guidelines for the anti-fraud program, ensuring alignment with enterprise objectives and applicable requirements. Recommends policy changes to mitigate FWA and improve processes. Plans, directs and/or oversees the development and implementation of advanced data analytics capabilities to detect, investigate, and report fraud, waste, and abuse. Oversees user adoption, training, and effective use of analytic models, dashboards, and workflows to improve lead generation, investigation efficiency, and mitigation outcomes.
• Serves as a primary liaison to build and sustain relationships with internal stakeholders and external partners to support the detection, investigation, reporting and mitigation of fraud, waste, and abuse. Coordinates timely information-sharing, referrals, and cooperative engagement strategies with vendors, industry associations, regulators and oversight entities, law enforcement, and government partners. Maintains productive relationships that support investigations and analytics capabilities, including setting expectations and escalating issues as needed. Represents the organization in appropriate industry forums to monitor emerging fraud schemes and strengthen program practices. Ensures all engagement is conducted in accordance with applicable confidentiality, governance, and compliance requirements.
• Leads and manages a team with the aim of driving effective performance management, fostering professional growth, and creating a positive and inclusive work environment. This role is dedicated to utilizing strong leadership and communication skills to motivate and inspire team members, ensuring they are aligned with and committed to achieving the organization’s goals.

Additional Responsibilities include:

• Performs other duties as assigned

• Complies with all policies and standards

The posting range for this position is:

130,608.85 - 176,628.63

Required Education, Certifications and Experience:

Education:

• Required - Required - BS in a related field or the equivalent of work experience

Experience:

• Required - 10+ Years staff and project management experience in insurance health care anti-fraud functions

Knowledge, Skills, and Abilities:

• Knowledge of the Blue Cross and Blue Shield system.

• Proven abilities to negotiate a position to others, to act independently and make appropriate decisions in complex situations, and to effectively present information and establish clear understanding and buy-in.

• Ability to conduct presentations to various groups, in both an informational and a training format.

• Demonstrated ability to develop and maintain relationships, while instilling a sense of professional confidence and trust is required.

• Ability to take action so that objectives and directives are executed timely and effectively.

• Excellent analytical skills and the ability to demonstrate independent business judgment and determine sound business-based conclusions are required, as well as superior written and verbal communication skills.

• Excellent organizational, project management, and leadership skills with ability to think strategically.

• Ability to maintain composure and tact in potentially adversarial situations, as well as the ability to manage and maintain confidential and sensitive information.

• Ability to adapt to changing situations by taking on ad hoc duties.

• Technical proficiency with various software applications to include Microsoft Windows, WORD, EXCEL, PowerPoint, and Outlook.

Certifications & Licenses

• Preferred: Certified Insurance Fraud Investigator (CIFI) - IASIU

Physical Demands/Working Environment

Physical Demands:

 Sedentary work (exerting up to 10 lbs. of force occasionally and involving sitting most of the time with occasional standing and walking)

Working Environment:

 Work is generally performed in an office or remote setting

Travel Requirements:

 Travel requirements for this position may vary based on project needs and client locations. Employees should be prepared for an estimated travel of 11-25% Meet with stakeholders and participate in training events.

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