Sr. Manager, Compliance and Ethics Investigations

Blue Shield of California•Oakland, CA

About The Position

Your Role The Compliance and Ethics team ensures adherence to the BSC Code of Conduct and owns and coordinates the Company’s compliance and ethics program across the enterprise, including all business units, products, services, and activities. This includes the implementation and maintenance of proper preventive, detective and remedial programs and controls; the execution of relevant policies and procedures; training and educating the workforce; implementing an effective communications program; ensuring effective testing, auditing, monitoring, tracking, and reporting; and remediate control deficiencies. This Senior Manager, Compliance and Ethics Investigations, is a critical senior manager and leader who reports to the Senior Director, Compliance and Ethics. The Compliance and Ethics Investigation team is responsible for managing internal investigations into potential violations of law, regulation, or company policy, ensuring that each investigation is handled promptly, confidentially, and in accordance with company policies and regulatory requirements. In this role, you will be accountable for leading a team of investigators and the end-to-end internal investigations of alleged misconduct, including matters related to fraud, violations of our Code of Conduct, conflicts of interest, inappropriate interactions with healthcare professionals, misuse of company, employee or patient information, and other compliance or regulatory concerns. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building, and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Requirements

Requires a bachelor’s degree or equivalent experience
Requires a minimum of 8 years prior relevant experience, including 3 years of management experience
Requires 4 years of experience supervising all, or key aspects, of a compliance and ethics program with increasingly progressive responsibility, combining results orientation and quality-driven attention to detail
A minimum of 7 years of demonstrated experience working with health plan operations and leadership or regulatory compliance experience strongly desired
Requires strong knowledge and broad understanding of the regulatory and compliance aspects of the healthcare industry, its products, and practices
Experience conducting or managing internal investigations in a corporate, legal or government enforcement setting
Demonstrated ability to lead sensitive investigations with discretion, independence, and professionalism
Knowledge of relevant regulations and guidance, including Foreign Corrupt Practices Act, False Claims Act, and OIG/DOJ guidance
Strong interviewing, analytical, and report-writing skills
Demonstrated approach to operating in a culture of continuous improvement and adaptability, particularly within changing regulatory environments
Exceptional influencing, interpersonal, written, and communication skills
High level of ethical standards and integrity, with a commitment to upholding the highest levels of ethical conduct within the organization

Nice To Haves

Healthcare, biotech, life sciences, or related industries a plus

Responsibilities

Lead the end-to-end internal investigations of alleged misconduct, including matters related to fraud, conflicts of interest, inappropriate interactions with healthcare professionals, misuse of company, employee or patient information, and other compliance or regulatory concerns
Conduct fact-finding interviews, review documentation and data, and develop clear, well-documented findings and recommendations
Develop and execute investigation plans, identifying key witnesses, documents, and systems for evidence collection
Partner with Legal, Employee Relations, Corporate Security, Internal Audit and other stakeholders to ensure investigations are coordinated, consistent, and aligned across the enterprise
Work closely with the investigations and hotline intake team to ensure accurate triage, categorization, and routing of concerns
Support the investigation function through intake process improvements, metrics and dashboard development, and preparation of Board and business level reports on trends and program effectiveness
Maintain, timely, complete case documentation in the case management system and ensure closure summaries meet program standards
Identify systemic issues and recommend process or policy improvements to prevent recurrence
Actively promote a culture of ethics, compliance, and “speak up” across the organization
Provide mentorship and guidance to junior investigators
Support continuous improvement of investigation protocols and tools, ensuring alignment with OIG/DOJ guidance and industry best practices