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Healthcare SIU Manager
About the position
Allied Universal® is hiring a Healthcare Special Investigations Unit Manager. The Healthcare Special Investigations Unit (SIU) Program Manager is responsible for the strategic oversight, operational leadership, and performance management of the Special Investigations Unit. This role supervises and directs investigative activities involving fraud, waste, and abuse (FWA) in government and commercial healthcare programs. The Healthcare Special Investigations Unit (SIU) Program Manager exercises independent judgment and discretion on matters of significance, including case strategy, regulatory interpretation, staffing decisions, risk mitigation, and external reporting to regulatory and law enforcement agencies.This position supervises professional investigative staff and is accountable for operational effectiveness, regulatory compliance, and measurable financial recoveries and cost avoidance.
Responsibilities
- Directly supervise, among others, SIU investigators, nurse auditors, documentation auditors, data analysts, and investigative support staff.
- Hire, train, evaluate, discipline, and terminate staff consistent with organizational policy.
- In partnership with other members of the senior leadership team establishes performance goals, productivity standards, and quality benchmarks.
- In partnership with other members of the leadership team and Human Resources Department develops succession planning and professional development pathways.
- Works effectively with the cross-functional team (Director, Sr. Director, Finance, Operations) manages departmental budgets, resource allocation, and vendor oversight.
- Provide strategic direction for complex FWA investigations involving providers, members, pharmacies, and ancillary entities.
- Review and approve investigative plans, case findings, referrals, and overpayment calculations.
- Ensure timely and compliant referrals to state and federal agencies, including HHS-OIG, DOJ, and Medicaid Fraud Control Units (MFCUs).
- Ensure SIU operations comply with the contract requirements, including state and federal regulations and reporting.
- Interpret federal and state fraud statutes and guidance for operational implementation.
- Oversee reporting obligations, including annual fraud plans and regulatory submissions.
- Collaborate with Compliance, Legal, Provider Relations, Claims Operations, and Pharmacy teams.
- Support internal audits and external regulatory examinations.
- Present case outcomes and risk exposure to executive leadership. Exercises independent discretion in investigative strategy and regulatory interpretation.
- Coordinates the approval of high-risk case referrals and law enforcement escalations.
- Determines staffing structure and workload distribution.
- Works with plans, outside leaders and Directors and Sr. Directors to authorize overpayment recoveries and civil action referrals within delegated authority.
- Responsible for department productivity and quality metrics.
Requirements
- Bachelor’s degree required (Criminal Justice, Healthcare Administration, Nursing, Accounting, or related field) with at least eight (8) years of progressive healthcare fraud investigation and/or payment integrity experience or
- Associate’s degree required (Criminal Justice, Healthcare Administration, Nursing, Accounting, or related field) with at least ten (10) years of progressive healthcare fraud investigation and/or payment integrity experience and/or
- High School Diploma or Equivalent with at least twelve (12) years of progressive healthcare fraud investigation and/or payment integrity experience and/or
- At least three (3) years in a supervisory or management role within the healthcare or investigative industry
- Experience with Medicare, Medicaid, and commercial insurance fraud investigations.
- Demonstrated experience interacting with law enforcement and regulatory agencies.
- Strong leadership, communication, problem-solving, and time management skills
- Knowledge of healthcare regulation and compliance policies
- Knowledge of medical terminology
- Critical thinking and analytical skills
- Proficiency in Microsoft Office
- Strong attention to detail and organizational skills
- Ability to maintain a high level of discretion with sensitive information
- Able to communicate effectively and professionally; oral and written
- Able to follow oral and written instructions
Nice-to-haves
- Advanced degree (JD, MBA, MHA, MPH) preferred.
- Certified Fraud Examiner (CFE).
- Accredited Health Care Fraud Investigator (AHFI).
- Certified Professional Coder (CPC) or Certified Professional Medical Auditor (CPMA).
- RN licensure (if clinically focused SIU oversight).
- Demonstrated ability to navigate and deliver in ambiguous, fast-paced environments.
- Strong analytical and problem-solving skills, with proficiency in tools such as Excel, PowerPoint, and data visualization platforms.
- Excellent written and verbal communication skills, with experience presenting to senior executives.
Benefits
- Medical, dental, vision, basic life, AD&D, retirement plan and disability insurance
- Seven paid holidays annually, sick days available where required by law
- Vacation time offered at an initial accrual rate of 3.08 hours biweekly for full time positions. Unused vacation is only paid out where required by law
