Business Compliance Manager (Aetna SIU)

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

Job summary

An established industry player is seeking a Manager of Business Compliance to lead a dedicated team in ensuring the integrity of healthcare fraud investigations. This role emphasizes training, quality review, and compliance with state regulations. You will collaborate with law enforcement and manage multiple projects while fostering a supportive environment for team development. With a focus on excellence, this position offers the opportunity to make a significant impact in the healthcare sector, ensuring that investigations are thorough and effective. Join a forward-thinking organization that values integrity and quality in its mission.

Benefits

Medical Plans

401(k)

Stock Purchase

Wellness Programs

Paid Time Off

Flexible Schedules

Qualifications

• 5+ years managing healthcare fraud investigations and compliance.
• Strong project management skills with the ability to handle multiple priorities.
• Experience collaborating with law enforcement agencies.

Responsibilities

• Lead a team to assess healthcare fraud and abuse investigations.
• Oversee quality reviews and ensure compliance with regulations.
• Manage team workload and support professional development.

Skills

Healthcare Fraud Investigation

Compliance Auditing

Project Management

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

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 the training and development of team members, managing quality review processes, and ensuring compliance with state regulations and contractual requirements.

What You Will Do

1. 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.
2. Oversee planning and execution of quality reviews related to healthcare fraud and abuse investigations involving both members and providers.
3. Provide guidance on case handling, facilitate issue resolution, and ensure high-quality investigations.
4. Identify resources and determine the best course of action in a timely and effective manner.
5. Conduct case reviews and give constructive feedback to team members on investigation quality and completeness.
6. Evaluate team members and support their professional development through ongoing performance feedback.
7. Manage team workload to ensure equitable case distribution, aligned with skills and development needs.
8. Assess training needs and collaborate with the SIU Sr. Manager to create development plans.
9. Build and maintain relationships with federal, state, and local law enforcement agencies to support investigations and prosecution.
10. Participate in state meetings and ensure contractual compliance.
11. Coordinate with compliance and leadership to align on program integrity initiatives.
12. Contribute to educational and training programs that meet or exceed state mandates.
13. Participate in federal and state audits to ensure compliance with regulations and standards.
14. Coordinate all aspects of the RFP lifecycle to meet organizational goals and deadlines.
15. Oversee vendor management, working closely with internal and external clients.
16. Manage multiple projects while leading a production team.
17. This role offers flexibility regarding location.

Required Qualifications

• Minimum five years managing healthcare fraud, waste, and abuse investigations, Compliance Auditing, Program Integrity, Regulatory Oversight, or Production Monitoring.
• At least four years of leadership experience managing teams of eight or more colleagues.
• Experience collaborating with law enforcement agencies.
• Strong project management skills with the ability to handle multiple priorities and meet deadlines.
• Excellent verbal and written communication skills.
• Ability to interact effectively across various groups and provide timely assistance.
• Proficiency in Microsoft Word, Excel, Outlook, SharePoint, QuickBase, Visio, and data analysis tools.
• Strong analytical skills supporting data-driven decision-making.
• Willingness to travel up to 20% (about 6-9 times per year).
• Comfortable presenting in large group sessions via videoconference or in person.

Preferred Qualifications

• Certifications such as CCEP, CFE, or similar.
• 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 a related field, or equivalent experience.

Additional Information

Full-time position, 40 hours per week. Salary range: $54,300 - $159,120, depending on experience and other factors. Includes benefits such as medical plans, 401(k), stock purchase, wellness programs, paid time off, flexible schedules, and more. For details, visit https://jobs.cvshealth.com/us/en/benefits.

Application deadline: 05/30/2025. Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws.