Special Investigations Unit (SIU) Manager of Audit/Clinical
$107,901–$172,642 year
RemoteUnited States
Job Summary
Lead and support a high-performing team of clinicians and coders focused on detecting, preventing, and correcting health care fraud, waste, and abuse. Manage processes for prepayment and post-payment medical record review inventory while ensuring SIU activities comply with legal, regulatory, and company requirements. Partner with internal and external stakeholders to develop strategies that support anti-fraud programs and advise team members on finalizing audit findings. Identify opportunities to leverage AI and data analytics to improve processes and strengthen outlier detection capabilities. Prepare the team for meetings with providers, regulators, and legal counsel while building relationships with industry peers to support strategic initiatives.
Required Qualifications
- Bachelor's degree
- 8+ years of relevant experience
- Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
- RN, PA, FNP or other APN certification
- LMSW, LCSW, LPC, LMFT, etc. licensure (for Behavioral Health specific roles)
- Authorization to work in the United States
- Hybrid Flex or Remote Flex work arrangement
- Communication
- Conflict Resolution
- Critical Thinking
- Decision Making
- Interpersonal Communication
- Leadership
- Legal Regulatory Compliance
- Negotiation
- Problem Solving
- Public Speaking
- Researching
- Strategic Planning
- Strategy Development
- Time Management
Desired Qualifications
- Experience leveraging data-driven insights to prioritize investigations, quantify financial impact, and support strategic SIU decision-making
- Data analytics, fraud detection modeling, and interpretation of complex healthcare claims data to identify emerging fraud, waste, and abuse trends
- Certified Professional Compliance Officer (CPCO)
- Certified Professional Coder (CPC) and other Specialty Certifications
- Statistics and Extrapolation
- Quality of Care Champion
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