Contract Fraud Investigator Jobs in Raleigh, NC (NOW HIRING)

Job Description

Blue Cross NC is hiring a Special Investigations Unit (SIU) Manager of Operations to lead the team responsible for key SIU functions. The SIU works to detect, prevent, and correct health care fraud, waste, and abuse while supporting the health and well-being of the customers and communities it protects, including Blue Cross NC employees, members, providers, and business partners.

What You'll Do

• Lead daily SIU operations, including intake, logging, triage, due diligence, and preliminary review of potential fraud, waste, and abuse incidents.

• Monitor external intelligence channels and manage prepayment intervention operations to support proactive anti-FWA efforts.

• Provide investigation support and oversee inbound and outbound correspondence related to SIU activities.

• Establish, monitor, and drive team performance metrics, production goals, and operational outcomes aligned to organizational priorities.

• Provide dynamic leadership, coaching, and professional development pathways for team members.

• Serve as a liaison with internal and external partners to develop, monitor, and update anti-FWA strategies and approaches.

• Represent the department on relevant internal committees and cross-functional initiatives, including presentations and active participation as needed.

• Ensure SIU activities comply with contracts, the Company Code of Conduct, the Company Compliance Program, the SIU Fraud Plan, and applicable state and federal guidelines.

• Leverage and develop AI-enabled tools to improve process efficiency and operational effectiveness.

What You Bring

• Bachelor's degree and 8+ years of relevant experience.

• In lieu of degree, 10+ years of experience in related field.

• Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) preferred

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

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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. Any fraudulent activity should be reported to: HR.Staffing@BCBSNC.com.