Senior Manager, SIU Fraud Investigation

Job 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. The role ensures timely, thorough, and well‑documented investigations; drives continuous improvement through monitoring of trends, root‑cause analysis, and corrective action; and establishes standards, procedures, and oversight mechanisms to support consistent case management, reporting, and outcome measurements across the enterprise. Responsibilities Supervises the detection, investigation, reporting and mitigation of fraud, waste and abuse across all lines of business. Oversees the development and 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 the 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, oversight entities, law enforcement, and government partners. Makes and escalates issues as needed to maintain productive relationships that support investigations and analytics capabilities. Represents the organization in 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 to drive effective performance management, foster professional growth, and create a positive and inclusive work environment. Performs additional duties as assigned. Complies with all policies and standards governing the role. Qualifications Education: BS in a related field or equivalent work experience. Experience: 10+ years of staff and project management experience in insurance or health‑care anti‑fraud functions. Knowledge, Skills, and Abilities: Knowledge of the Blue Cross and Blue Shield system. Strong negotiation skills; ability to act independently and make appropriate decisions in complex situations. Effective presentation skills for both informational and training formats. Ability to develop and maintain professional relationships, instilling confidence and trust. Reliable execution of directives and timely action to achieve objectives. Excellent analytical skills with independent business judgment and sound business‑based conclusions. Superior written and verbal communication skills. Organizational, project management, and leadership skills with strategic thinking. Ability to maintain composure and tact in potentially adversarial situations and manage confidential, sensitive information. Adaptability to changing situations and willingness to perform ad hoc duties. Technical proficiency with Microsoft Windows, Word, Excel, PowerPoint, and Outlook. Preferred Certifications Certified Insurance Fraud Investigator (CIFI) – IASIU. Physical Demands / Working Environment • Sedentary work (exerting up to 10 lbs. of force occasionally and involving sitting most of the time with occasional standing and walking). The work is generally performed in an office or remote setting. Travel Requirements • Travel may vary based on project needs and client locations; employees should be prepared for an estimated travel of 11-25%. Compensation and Benefits • Posted salary range: $130,608.85 - $176,628.63. The range may be modified in the future. This role is also eligible for annual bonus incentive pay. • Comprehensive benefits package includes paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account, and many other benefits to eligible employees. Equal Employment Opportunity This organization is an equal opportunity employer and does not discriminate based on race, religion, color, national origin, gender, gender identity, sexual orientation, disability or any other legally protected class. #J-18808-Ljbffr 001_BCBSA Blue Cross and Blue Shield Association