Sr. Director, Senior Associate General Counsel, Fraud Investigation & Prevention

Ready to help us transform healthcare? Bring your true colors to blue.

Is this the next step in your career Find out if you are the right candidate by reading through the complete overview below.

Blue Cross Blue Shield Massachusetts is seeking an experienced litigator to join its fast-paced and collegial in-house legal department.

The attorney will oversee the fraud investigations unit and its work pursuing recoveries for fraud and improper billing.

The attorney will be responsible for the unit’s finances including both setting and managing business and financial goals.

This attorney will act as an interface between BCBSMA and outside entities including law enforcement and national antifraud associations.

The attorney will also oversee compliance for the Medicare and Federal Employee programs related to FWA and respond to Compliance, CMS and OPM requests and audits.

The attorney will provide risk management advice, legal advice and litigation services to other areas of the Blue Cross as needed.

This may include representation of Blue Cross in both federal and state courts and in administrative hearings concerning a wide variety of legal claims.

The attorney will also interact with other business areas to effectuate corporate goals.

Key Accountabilities :

• Oversee the Fraud Investigation and Prevention (FIP) Unit including management of a team of senior managers, data analysts, fraud investigators, certified coders and medical providers.
• Manage strategy, goal setting and budget for the FIP Unit including work on division plans and corporate goals, and presentations to various committees including Compliance Oversight, Risk Management and the Audit Committee of the Board.
• Manage interactions and collaboration with senior business leaders, the Board and other business units to advance the work of the FIP Unit and support Blue Cross’ management of risk related to fraud.
• Manage interactions with Accounts, members and other stakeholders related to fraud matters.
• Manage inquiries and interactions with law enforcement, regulators and legislators at both the state and federal levels to help achieve FIP Unit goals, support antifraud initiatives and provide guidance on potential regulations impacting fraud investigation work.
• Oversee and act as legal counsel to the FIP Unit providing advice and guidance throughout each stage investigation through to resolution which could include settlement and / or litigation or law enforcement activity.
• Effectively collaborate with outside counsel in a variety of litigation-related matters.
• Represent BCBSMA in interactions with regulatory agencies and in responding to subpoenas or other civil investigatory demands.
• Provide pre-litigation and risk management advice to the business regarding the creation of controls to manage fraud, waste and abuse schemes.
• Support the Medicare compliance program by overseeing Medicare fraud waste and abuse activity in FIP, work with the Pharmacy Benefit Manager on fraud waste and abuse work, present to the Medicare Compliance Committee and manage requests and audits from CMS.
• Support the Federal Employee compliance program by overseeing FEP fraud waste and abuse activity in FIP and manage requests and audits with OPM and the Blue Cross Association.
• Support company business initiatives by providing guidance and judgment regarding the complex and evolving legal environment as it relates to FWA matters.
• Collaborate with business leaders both on complex legal matters and business matters by effectively communicating with various stakeholders and providing potential solutions to identified issues.

Qualifications (knowledge / skills / abilities / behaviors) :

• Excellent presentation skills, including the ability to persuasively present cases, business matters and legal advice to the Board, senior management, peer review committees or government officials.
• Excellent negotiation skills and experience dealing with opposing counsel and negotiating settlements.
• Ability to negotiate with and influence different business areas in a constructive manner to achieve division and corporate goals.
• Skill to solve problems independently along with willingness to work as a team member.
• Demonstrated experience litigating matters in court and before administrative agencies.
• Ability to understand and quickly learn new areas of the business and the law and provide counsel and expertise to the business on those areas.
• Excellent business acumen and judgment, including ability to place legal risk in proper business context.
• Effective collaboration with key business areas.
• High degree of professionalism along with ability to influence peers and leaders at all levels, both within Blue Cross and external to Blue Cross.
• Excellent written and oral communication skills.
• Strong organizational and prioritization skills; ability to manage multiple priorities effectively.
• Flexibility and interest in taking on additional work / projects as opportunities or need arise.

Education / Relevant Experience :

• BA and JD degrees.
• Massachusetts license to practice law and member in good standing.
• 7+ years of complex litigation experience, preferably related to healthcare and / or law enforcement work.
• Experience managing teams.
• Preferred prosecutorial or law enforcement background.
• Preferred AFHI, CFE or equivalent certification.
• Experience with ERISA benefit plans, Medicare and / or health insurance a plus.

Minimum Education Requirements :

High school degree or equivalent required unless otherwise noted above.

Location Boston Time Type Full time

Salary Range : $232,470.00 - $284,130.00

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting.

We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical / dental / vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note : No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable.

The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply.

We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA.

The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant.

We encourage you to bring us your true colors, your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success.

Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page.

If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay in the know on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work / life balance is a key part of associate wellbeing.

For more information on how we work and support that work / life balance visit our "How We Work" Page.

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