Business Compliance Manager (Aetna SIU)

Hispanic Alliance for Career Enhancement; City of Mechanicville (NY); Hybrid; USD 54,000 - 160,000; Full time

Job summary

Join a forward-thinking organization as the Manager of Business Compliance for Quality Review, Training, and Program Integrity. In this pivotal role, you'll lead a dedicated team focused on ensuring the integrity of healthcare fraud investigations. Your expertise will guide the development of training programs and quality review processes, while fostering strong relationships with law enforcement agencies. This position offers the chance to make a significant impact in a dynamic environment, where your leadership and analytical skills will drive successful outcomes. If you're passionate about healthcare compliance and team development, this is the opportunity for you.

Qualifications

• 5+ years managing healthcare fraud and abuse investigations.
• Experience leading teams of 8+ colleagues.
• Strong project management and analytical skills.

Responsibilities

• Lead a team to assess healthcare fraud investigations.
• Oversee quality reviews and ensure compliance with regulations.
• Manage team performance and provide training support.

Skills

Healthcare Fraud Investigation

Compliance Auditing

Project Management

Data Analysis

Team Leadership

Communication Skills

Analytical Skills

Education

Bachelor's degree in Business Administration

Healthcare Administration

Criminal Justice

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

SharePoint

QuickBase

Visio

Job description

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels, and more than 300,000 purpose-driven colleagues—caring for people where, when, and how they choose in a way that is uniquely more connected, more convenient, and more compassionate. And we do it all with heart, each and every day.

Position Summary

As the Manager of Business Compliance for Quality Review, Training, and Program Integrity, you will lead a team responsible for ensuring the quality and integrity of healthcare fraud and abuse investigations. This role involves overseeing the training and development of team members, managing quality review processes, and ensuring compliance with state regulations and contractual requirements.

What You Will Do

• Lead a team of Quality Reviewers to effectively assess the prevention, investigation, and prosecution of healthcare fraud and abuse, ensuring the recovery of lost funds.
• Oversee the planning and execution of quality reviews for investigations related to acts of healthcare fraud and abuse by both members and providers.
• Provide direction and counsel on case handling, facilitate issue resolution, and ensure high-quality investigations.
• Assist in identifying resources and determining the best course of action in a timely and effective manner.
• Conduct comprehensive case reviews and provide constructive feedback to team members on investigation quality.
• Evaluate team members and provide ongoing performance feedback to support their professional development.
• Manage the workload of the team to ensure equitable distribution and exposure to a wide range of cases, aligned with current skills and development needs.
• Assess training needs and collaborate with the SIU Sr. Manager to create development plans for team members.
• Develop and maintain strong relationships with federal, state, and local law enforcement agencies to support investigations and prosecution of healthcare fraud and abuse.
• Participate in state meetings and ensure compliance with contractual requirements.
• Coordinate with compliance and senior leadership to align on program integrity initiatives.
• Contribute to the development and delivery of educational awareness and training programs that meet or exceed state mandates.
• Participate in federal and state audits to ensure adherence to regulations and standards.
• Oversee the coordination of the RFP lifecycle to meet organizational goals and deadlines.
• Manage vendor relationships, working closely with internal and external clients.
• Manage multiple projects while leading a production team.
• This role offers flexibility regarding location.

Required Qualifications

• Minimum of five years managing healthcare fraud, waste, and abuse investigations, Compliance Auditing, Program Integrity, Regulatory Oversight, or Production Monitoring.
• At least four years of experience leading teams of eight or more colleagues.
• Experience collaborating with state and law enforcement partners.
• Proven project management skills, with the ability to manage multiple priorities and meet deadlines.
• Strong verbal and written communication skills.
• Effective interaction with diverse groups at various levels and providing timely assistance.
• Proficiency in researching information and utilizing relevant resources.
• Comprehensive knowledge of Microsoft Word, Excel, Outlook, SharePoint, QuickBase, Visio, and data analysis tools.
• Strong analytical skills supporting data-driven decision-making.
• Ability to travel up to 20% (approximately 6-9 times per year).
• Comfortable presenting in large group sessions via videoconference or in person as defined by leadership.

Preferred Qualifications

• Certifications such as CCEP, CFE, or similar credentials.
• Experience managing a quality assurance team, including staff training and development.
• Knowledge of company policies and procedures.
• Familiarity with Medicaid and Medicare plans.

Education

• Bachelor's degree in Business Administration, Healthcare Administration, Criminal Justice, or related field, or equivalent experience.

Additional Details

Anticipated weekly hours: 40

Time type: Full time

Pay range: $54,300 - $159,120, with actual offer based on experience, education, location, and other factors. Eligible for bonuses and incentives.

We value diversity and inclusion, and all qualified applicants will be considered without regard to arrest or conviction records, in accordance with applicable laws.