Sr. Manager, Major Case Investigative Unit (Medical & Provider Fraud)

The Opportunity

We are seeking a highly analytical and strategic Senior Manager - Major Case Investigative Unit to lead our fight against insurance fraud. In this newly created role, you will bridge the gap between First Party Medical (FPM) operations and the Special Investigative Unit (SIU). Your role will be to collaborate closely with SIU and FPM leadership to drive cross-functional projects and business solutions. Your primary mission will be to aggressively identify, investigate, and combat 1st and 3rd party medical fraud, with a specialized focus on complex provider fraud rings and schemes.

What You Will Need to Succeed

• 5+ years of progressive leadership experience in P&C Insurance, specifically overseeing First Party Medical (PIP/No-Fault) claims and/or Medical related Special Investigative Units (SIU).
• Deep subject matter expertise in medical provider fraud, upcoding, unbundling, and complex multi-party clinic schemes.
• Extensive experience managing medical claims and fraud investigations in New York, Michigan, New Jersey, and Florida (highly preferred).
• Proven ability to manage and balance highly technical metrics, including cycle times, RTQA results, and closure rates.
• Ability to identify broader fraud trends across organizations and build actionable defense strategies.

How You Will Make an Impact

• Oversee the strategy and handling of complex cases that tend to involve multiple claims, parties, and schemes.
• Direct projects and initiatives related specifically to major case and provider fraud initiatives.
• Ensure leaders drive investigations that are conducted in a thorough, efficient manner that is completely compliant with laws, regulations, and ethics.
• Monitor trends with lawsuit filings for FPM and Injury.
• Manage defense spend per matter, taking specific venue nuances into consideration.
• Lead and develop a collaborative team where everyone is engaged, empowered to express their ideas, and motivated to drive the organization forward through challenges.
• Control inventory by ensuring proactive and efficient investigations that align with the established procedures.
• Maintain an environment where the importance of employee empowerment does not get lost in the day-to-day operations of running a claims department.
• Recruits, retains and develops a highly motivated and accountable team of experienced and developing claim professionals.
• Lead teams investigating claims that are geographically dispersed across the country.
• Drive pace within the team, resulting in best-in-class LAE while maintaining high employee satisfaction.
• Help establish and drive adherence to processes to drive technical claim handling, resulting in best-in-class loss performance while maintaining high customer satisfaction.
• Use internal controls associated with claims payments and quality of file handling.
• Advocates for talent and builds capabilities to ensure strong leadership and technical talent bench strength.
• Provides expertise to the team in reviewing, researching, investigating, negotiating, processing and adjusting claims.