Special Investigations Unit (SIU) Manager of Operations

Blue Shield of North Carolina • Durham, NC

4d • Hybrid

About The Position

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.

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

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.

Responsibilities

• 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.

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