Business Compliance Manager (Aetna SIU)

Hispanic Alliance for Career Enhancement; Olympia (WA); Remote; USD 54,000 - 160,000; Full time

Job summary

An established industry player is seeking a dedicated Manager of Business Compliance to lead a dynamic team focused on healthcare fraud investigations. This role is pivotal in ensuring the integrity and quality of investigations while fostering professional growth among team members. You will collaborate with law enforcement and oversee training initiatives, making a significant impact in the healthcare compliance landscape. With a flexible location and a comprehensive benefits package, this opportunity is perfect for a passionate leader eager to drive change and uphold standards in the healthcare sector.

Benefits

Comprehensive medical benefits

401(k) retirement plan

Stock purchase plan

Wellness programs

Qualifications

• 5+ years managing healthcare fraud investigations and compliance auditing.
• Strong project management skills and team leadership experience.
• Proficient in data analysis for effective decision-making.

Responsibilities

• Lead a team to ensure quality and integrity in healthcare fraud investigations.
• Oversee training and development of team members.
• Manage multiple projects while ensuring compliance with regulations.

Skills

Healthcare fraud investigation

Compliance auditing

Project management

Data analysis

Verbal and written communication

Team leadership

Education

Bachelor's degree in Business Administration

Bachelor's degree in Healthcare Administration

Bachelor's degree in Criminal Justice

Tools

Microsoft Office Suite

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

We are seeking a 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 team training and development, managing quality review processes, and ensuring compliance with state regulations and contractual requirements.

What You Will Do

• Lead a team of Quality Reviewers to assess the prevention, investigation, and prosecution of healthcare fraud and abuse, ensuring the recovery of funds.
• Oversee planning and execution of quality reviews related to healthcare fraud and abuse investigations involving members and providers.
• Provide guidance on case handling, facilitate issue resolution, and ensure high-quality investigations.
• Identify resources and determine the best course of action promptly and effectively.
• Conduct comprehensive case reviews and give constructive feedback to team members.
• Evaluate performance and support professional growth through ongoing feedback.
• Manage workload distribution to ensure exposure to diverse cases aligned with team skills and development needs.
• Assess training needs and collaborate with the SIU Sr. Manager to develop training plans.
• Build and maintain relationships with federal, state, and local law enforcement to support investigations and prosecutions.
• Participate in state meetings and ensure contractual compliance.
• Coordinate with compliance and leadership on program integrity initiatives.
• Contribute to educational and training programs to meet or exceed state mandates.
• Participate in audits to ensure regulatory adherence.
• Oversee vendor relationships, working with internal and external stakeholders.
• Manage multiple projects while leading a production team.
• Flexible location.

Required Qualifications

• At least five years managing healthcare fraud, waste, and abuse investigations, compliance auditing, program integrity, or regulatory oversight.
• Minimum of four years in a leadership role supervising teams of eight or more colleagues.
• Experience collaborating with law enforcement agencies.
• Strong project management skills, capable of handling multiple priorities.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office Suite, SharePoint, QuickBase, Visio, and data analysis tools.
• Strong analytical skills for data-driven decision-making.
• Willingness to travel up to 20%.

Preferred Qualifications

• Certifications such as CCEP, CFE, or similar.
• Experience managing quality assurance teams, including staff training and development.
• Knowledge of company policies, Medicaid, and Medicare plans.

Education

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

Additional Details

• Full-time, 40 hours/week.
• Pay range: $54,300 - $159,120, based on experience and location.
• Comprehensive benefits including medical, 401(k), stock purchase, wellness programs, and more.