“Making Healthcare Right. Together.” is the cornerstone of all we do. Our vision is through powerful relationships with Care Partners, we help all people live healthy and brighter lives. To successfully achieve our mission and vision as we operate in a dynamic health care environment, we expect Bright employees to embody and uphold our core values in work and interactions, both internal and external: be brave, be brilliant, be accountable, be inclusive, and be collaborative.
ABOUT THE ROLE
Under the direction of the Director of Compliance, the Manager, Special Investigations Unit (SIU) will work to build out a shared service Fraud, Waste, and Abuse function. The Manager will be responsible for overseeing investigation activities, building the Bright Health SIU program/shared service function, and contributing to the development and administration of FWA analytical tools. The Manager will also be responsible for oversight of delegate FWA activities, monitoring, reporting, and representing the SIU to both internal and external parties.
- Intake and review reported instances of suspected fraud, waste, and/or abuse
- Performs investigation of credible instances of suspected fraud, and coordinates communication with all parties involved
- Prepare reporting for internal analysis and external reporting requirements
- Develop tools, templates, and strategies to proactively analyze data and identify potential FWA trends
- Lead the SIU shared service program development
- Fulfill response requests for Requests for Information (RFI) and other external requests from state and federal regulators, attorneys, and other entities as necessary
- Provide FWA training and contribute to the develop of FWA training materials at Bright Health
- Support integration activities as they relate to enterprise acquisitions
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s degree required
- At least one of the following: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Anti-Money Laundering and Fraud Professional (CAFP), Certified Professional Coder (CPC) or similar certification/credential
- At least five (5) years of experience performing SIU investigations at a healthcare company required, Five to Seven (5-7) years of experience preferred
- Health insurance experience preferred
- Ability to gather and analyze data sets
- Strong presentation skills
- Ability to work collaboratively with both internal and external stakeholders
- Knowledge of the regulatory landscape as it applies to FWA
- Experience with HIPAA and data privacy/security
LICENSURES AND CERTIFICATIONS
- An active, unrestricted Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Anti-Money Laundering and Fraud Professional (CAFP), Certified Professional Coder (CPC) or similar certification/credential is required
At Bright Health, we brought together the brightest minds from the health care industry and consumer technology, and together we created Bright Health: a new, brighter approach to healthcare, built for individuals. Our plans are easy to manage, personalized, and more affordable, giving people the quality care they deserve. Through our exclusive care partnerships with leading health systems in local communities, we are reshaping how people and physicians achieve better health together.
We’re Making Healthcare Right. Together.
We've won some fun awards like Modern Healthcare and Forbes, etc. But more than anything, we're a group of people who are really dedicated to our mission in healthcare. Come join our team!
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.