Attorney in Fort Lauderdale, FL

In-House

Fort Lauderdale, FL

Attorney in Fort Lauderdale, FL

Non-practicing Attorney

Min 10 yrs required

No

Job Title: Vice President, Special Investigations Unit

Job Responsibilities:

- Lead a team of investigators, clinical and coding reviewers, and analysts dedicated to detecting, preventing, and correcting fraud, waste, and abuse (FWA) in healthcare billing.
- Design and execute strategies to ensure high-quality, timely, value-generating FWA investigations in compliance with legal, regulatory, and contractual requirements.
- Provide oversight of FWA investigative activity affecting the company's markets and products and collaborate with internal and external stakeholders, including law enforcement.
- Develop and execute a forward-looking FWA investigation strategy aligned with regulatory obligations and business priorities.
- Partner with colleagues in Compliance and Legal to ensure investigations and reporting meet federal and state mandates, including CMS and state Medicaid program requirements.
- Oversee the intake, triage, investigation, and resolution of suspected FWA cases.
- Implement technology and analytics tools to proactively identify risk patterns and trends.
- Establish KPIs and operational dashboards to monitor team performance, ensure case quality, and promote efficiency.
- Maintain clear documentation and governance frameworks for SIU operations and decision-making.
- Stay informed of FWA-related developments and trends in the healthcare industry and share actionable knowledge and guidance with colleagues.
- Serve as a trusted partner to market, product, and operational leadership to assist in identifying vulnerabilities and embedding FWA prevention controls.
- Cultivate external partnerships with regulators, state and federal law enforcement, and national FWA coalitions.
- Ensure timely and accurate reporting of FWA metrics and case data to appropriate regulatory bodies and the company's executive leadership.
- Act as a member of the Compliance Department leadership team and participate in policy development, training, communication, planning, and other departmental leadership activities.
- Represent the SIU at audit, board, and regulatory meetings as appropriate.
- Demonstrate the company's core values of Accountability, Curiosity, Courage, Trust, and Service in day-to-day communication and actions.
- Perform other duties as assigned and comply with all policies and standards.

Education and Experience Information:

- Bachelor's Degree in Business Administration, Healthcare Administration, Law, or related field required.
- Master's Degree in Business Administration, Healthcare Administration, Law, related field or Juris Doctor (JD) preferred.
- 10+ years of progressive experience in fraud investigations, healthcare compliance, or regulatory enforcement required.
- Significant experience managing large-scale FWA programs in a health plan, payer, government agency, or consulting firm required.
- Deep knowledge of federal and state health programs (Medicare, Medicaid) and FWA regulatory frameworks (., CMS, SIU mandates) required.
- Proven leadership experience with cross-functional teams, external regulators, and law enforcement entities required.
- Strong data literacy and familiarity with fraud analytics tools and methodologies required.
- Excellent executive communication, risk judgment, and ethical decision-making skills required.
- Experience leading SIU operations in a multi-state or national managed care organization preferred.
- Ability to operate effectively in a complex, matrixed environment preferred.
- Track record of innovation in fraud detection and use of emerging technologies preferred.
- Deep commitment to the company's mission of transforming the health of the community, one person at a time preferred.

Licenses/Certifications:

- CFE, AHFI preferred

Salary Information:

- Pay Range: $182, - $345, per year
- The company offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field, or office work schedules.
- Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.
- Total compensation may also include additional forms of incentives.
- Benefits may be subject to program eligibility.

The company is an equal opportunity employer committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristics protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws and ordinances.