Special Investigations Unit Director jobs in Berkeley, CA

The Director of Special Investigations is responsible for oversight of the Special Investigations Unit, ensuring strategic direction and implementation of effective prevention, detection, investigation, reporting, and recovery techniques to mitigate company exposure related to fraud.

This individual will serve as a member of our Senior Leadership Team and work collaboratively with fellow Claims, Medical Management, Underwriting, Premium Audit, Finance, and Legal leadership to leverage resources and drive innovative approaches to reduce company losses.  

ONSITE REQUIREMENT (NON-NEGOTIABLE)

This is a hybrid opportunity with a minimum requirement of three days per work week in our Walnut Creek, CA office; Wednesday being a required all-hands Collaboration Day.

LEADERSHIP RESPONSIBILITIES

This position relies on extensive experience, keen judgment, and strong leadership skills to perform the functions of the job and achieve results in established timelines. Takes a proactive approach to anticipating and solving problems.  Ensures that employees understand their level of accountability and takes appropriate action to ensure employees fully understand roles, responsibilities, and performance standards, and provides ongoing feedback and support. Executes responsibilities professionally and in accordance with the Company’s policies and applicable laws. 

• Develops, directs and evaluates investigative strategies, practices, policies and performance standards to ensure desired outcomes are achieved in alignment with the department’s mission and operational goals.  Instills operational discipline and ensures adherence to company guidelines, policies, procedures and compliance with applicable regulatory requirements. 
• Collaborates with key Senior Leadership (Claims/Medical Management, Underwriting, Premium Audit, Finance, Legal) to refine and maintain SIU best practices and processes to prevent, detect, investigate and ensure timely reporting of suspected fraudulent activity.
• Creates and facilitates required fraud detection/prevention training to company staff.  Ensures timely, thorough recordation of participation and completion is maintained and forwarded to proper regulatory authority. 
• Helps achieve successful investigative outcomes by providing expertise and ensures the internal team and external defense attorneys are providing appropriate legal support to assist in attaining timely and effective outcomes. Ensures investigations are conducted in compliance with applicable statutes, regulations, case law, and company standards.
• Provides investigative support for Lien Unit and external counsel as requested for litigation addressing issues associated with suspected fraud or abuse of billing and reporting practices. 
•  Leads efforts to partner with internal and external legal and investigative resources to ensure successful strategic outcomes at a competitive cost.  Compiles data to monitor effectiveness of outcomes and implements changes as needed to accomplish fruitful, cost-effective results consistent with regulatory and industry standards/trends and corporate objectives.
•  Understands critical business goals and determines the talent development needs within the team to support these goals.  Aligns with Human Resources and COO to attain top talent and ensure continued engagement of team members via educational opportunities, effective performance feedback, mentorship, recognition or disciplinary action as necessary, and competitive compensation. 
• Participates as an accountable member of the Senior Leadership Team and promotes company strategies and values.

• EDUCATION/EXPERIENCE:  Juris Doctor or minimum of Bachelors degree in Criminal Justice, Psychology, Sociology, Business Administration, Finance, or related major from an accredited college or university; or, minimum of ten (10) years of relevant experience in special investigations within workers compensation, insurance fraud and abuse, or law enforcement, with a minimum of five (5) years of progressive managerial experience directing investigative personnel with complex workflows (e.g., regulatory reporting); or, a combination of relevant education and industry training and experience. 
• CERTIFICATIONS/LICENSES:  One or more of the following preferred:  Active license in good standing to practice law in one or more jurisdictions; Certified Fraud Examiner (ACFE); Certified Insurance Fraud Investigator (CIFI); Chartered Property Casualty Underwriter (CPCU); Self-Insurance Certification (Claims/SIP)
•  LANGUAGE ABILITY: Able to read, analyze, interpret and advise regarding complex governmental regulations, legal opinions, claims laws and regulations, technical claims processes and procedures relating to fraud detection/prevention, and medical billing and reports.  Able to effectively present information and respond to questions from Executive management, vendor partners, legal counsel or authority, and the general public. Able to respond to technical inquiries from internal and external sources, and regulatory agencies.
• MATH AND REASONING ABILITY: Able to solve practical problems and deal with a variety of variables in situations where only limited standardization exists. Able to interpret instructions furnished in written, oral, diagram, or schedule form.  Relies on extensive experience and judgment to plan and accomplish goals.
• TECHNICAL AND COMPUTER SKILLS: 
• Strong business and industry regulatory acumen complemented by claims adjusting knowledge, premium and medical billing familiarity, and industry best practices in risk management and fraud detection/prevention.
• Advanced communication and presentation skills with ability to deliver complex information effectively to Executive management in order to achieve objectives.
• Solid knowledge of Microsoft Office applications and job-related proprietary software. Knowledge of Power BI, SQL highly preferred.  
• TRAVEL: Occasional travel to other corporate offices or vendor locations required.

In accordance with the California Equal Pay Act, the pay scale for this job is $166,220 - $211,200.  This pay scale is an estimate of the salary range the employer reasonably expects to pay for the position based on potential employee qualifications, operational needs and other considerations consistent with applicable law. The actual salary may be above or below the range. The pay scale applies only to this position and only if it is filled in California. The pay scale may be different for other positions or in other locations.