What You'll Do Investigation Oversight:

Assign and manage case inventory, support investigative action plans, and drive timely, thorough investigations from intake through resolution.

Case Quality and Compliance:

Review cases to ensure documentation meets quality standards, confirm referrals to internal and external stakeholders are completed in accordance with policy, and advise on final case disposition, including engagement with internal and external counsel.

Team Leadership and Development:

Provide investigative guidance and subject matter expertise to team members, support professional growth opportunities, and help drive team performance in alignment with organizational strategies and goals.

Strategic Partnership:

Serve as a liaison with industry peers and key internal and external partners to support tactical and strategic initiatives related to fraud, waste, and abuse prevention.

Program Leadership:

Provide dynamic leadership for SIU team members and participate in internal committees, cross-functional presentations, and initiatives related to SIU responsibilities.

Anti-FWA Strategy:

Develop, monitor, and update approaches and strategies that strengthen anti-fraud, waste, and abuse programs.

Regulatory Alignment:

Ensure SIU activities comply with applicable internal and external legal, contractual, regulatory, and policy requirements, including the Company Code of Conduct, Compliance Program, SIU Fraud Plan, and state and federal guidelines.

Process Improvement:

Leverage and support the development of AI-enabled solutions to improve process efficiency. What You Bring Minimum of a Bachelor's degree preferred In lieu of degree, 10+ years of experience in related field. Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) 8+ years of experience conducting/leading healthcare fraud investigations Bonus Points 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 What You'll Get The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community. Work-life balance, flexibility, and the autonomy to do great work. Medical, dental, and vision coverage along with numerous health and wellness programs. Parental leave and support plus adoption and surrogacy assistance. Career development programs and tuition reimbursement for continued education. 401k match including an annual company contribution. Learn more Where You'll Work Our Hybrid Flex approach is built on presence with a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplace that's flexible, connected, and future focused. In a Hybrid-Flex role, you'll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you'll work virtually, with a few in-office visits each year for meaningful moments that matter. Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process. Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus•, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. •Based on annual corporate goal achievement and individual performance. $107,901.00 - $172,642.00 Skills 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 _____________________________________________________________________

JOB ALERT FRAUD

We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC . If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. 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Special Investigations Unit (SIU) Manager of Investigations