Special Investigations Unit (SIU) Manager of Audit/Clinical

Blue Cross and Blue Shield of North Carolina

5d • $107,901 - $172,642 • Hybrid

About The Position

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.

Requirements

• 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.).
• 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

Nice To Haves

• 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

Responsibilities

• 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.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager