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Job Description

Blue Cross NC is hiring a Special Investigations Unit (SIU) Manager of Audit/Clinical to lead a team of clinicians and coders focused on detecting, preventing, and correcting health care fraud, waste, and abuse. This role ensures patient care is accurately documented and billed according to standards while supporting SIU's mission to protect and improve the health and well-being of Blue Cross NC employees, members, providers, business partners, and the communities it serves.

What You'll Do

• Lead and support a high-performing team aligned to organizational strategies, goals, and performance expectations.

• Provide engaging, effective leadership for a remote workforce, including coaching, feedback, and professional development support.

• Partner with internal and external stakeholders to develop, monitor, and refine strategies that support anti-fraud, waste, and abuse programs.

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

• Identify opportunities to use AI and other tools to improve processes, increase efficiency, and strengthen team outcomes.

• Create forums for team members to apply clinical expertise throughout the investigative process.

• Bring a clinical perspective to ideation sessions that support the ongoing development of advanced outlier detection analytics.

• Manage processes and workflows for prepayment and post-payment medical record review inventory.

• Establish, monitor, and report on team performance, production metrics, and goals.

• Advise team members as they finalize audit and clinical findings, including internal peer review activities.

• Prepare the team for meetings with providers, state and federal regulators, legal counsel, and other internal or external stakeholders.

• Build relationships with industry peers to support tactical and strategic initiatives.

• Contribute to operational strategies and innovative solutions that strengthen audit and clinical oversight.

• Stay informed on health care trends, industry developments, and government regulations, and recommend policy positions, new initiatives, or program improvements as needed.

• Collaborate with leaders who manage vendor relationships that support business area needs.

• Lead or participate in internal committees related to the role, including representing the department through presentations and cross-functional collaboration.

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

• RN, PA, FNP or other APN certification. For Behavioral Health specific roles, other applicable licensures will be considered (LMSW, LCSW, LPC, LMFT, etc.).

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

• Quality of Care Champion

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.