The Role
Lead and oversee the Fraud, Waste, and Abuse (FWA) Special Investigations Unit: ensure regulatory compliance, manage investigations and outcomes, coordinate cross-functionally and with vendors, escalate major risks, supervise staff, monitor program metrics, and support audit and regulatory responses.
Summary Generated by Built In
Job Summary & Responsibilities
- Program Oversight/Leadership for FWA SIU:
- Provide strategic oversight of the FWA SIU program
- Ensure compliance with all applicable FWA regulatory requirements
- Maintain independence and objectivity of SIU investigations
- Oversee intake, prioritization, and outcomes of investigations
- Review and approve investigative findings and referrals
- Escalate significant FWA risks to executive leadership
- Oversee vendor and delegated FWA/SIU activities
- Monitor FWA trends, metrics, and program effectiveness
- Oversee FWA related reporting
- Support audit readiness and regulatory inquiries
- Cross-Functional Team Partnerships:
- Partner with Compliance to ensure regulatory alignment and audit readiness
- Collaborate with Medical Management on utilization and clinical FWA risks
- Coordinate with Provider Relations on provider actions and remediation
- Work with Finance on recoveries, overpayments, and financial reporting
- Coordinate with Legal as appropriate on investigations, and enforcement actions
- Support Operations with FWA education, guidance, and risk mitigation
- Coordinate with delegated entities and vendors on FWA oversight and reporting
- Serve as the primary SIU liaison to internal and external stakeholders
- Leadership:
- Selects, trains, develops and organizes staff.
- Monitors overall inventory of work and prioritizes the staff's work to meet performance standards and authorizes additional resources as needed.
- Provides feedback and coaching (helping individuals to solve problems/issues on their own) including timely completion of any interim and year-end performance reviews.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid
Preferred Qualifications- Bachelor's degree and five years of related work experience; or equivalent combination of education and work experience.
- Three years of supervisory or management experience.
- Effective verbal and written communication skills.
- Collaborative crisis management skills.
- Ability to develop programs based on relevant industry best practice and regulations.
- Interpretation of government regulations and applicable codes to ensure compliance.
- Basic working knowledge of Microsoft Office application, including word, excel, powerpoint, outlook.
Skills Required
- Bachelor's degree and five years of related work experience or equivalent combination of education and work experience
- Three years of supervisory or management experience
- Effective verbal and written communication skills
- Collaborative crisis management skills
- Ability to develop programs based on relevant industry best practices and regulations
- Ability to interpret government regulations and applicable codes to ensure compliance
- Basic working knowledge of Microsoft Office applications (Word, Excel, PowerPoint, Outlook)
HMSA Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about HMSA and has not been reviewed or approved by HMSA.
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Healthcare Strength — Medical and dental coverage are described as solid, with preventive services and select zero‑cost features adding value in recent plan years. Employer-sponsored plans can have affordable premiums in certain groups and broad access options.
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Retirement Support — A 401(k) with company match and potential discretionary contributions forms a strong component of total rewards. Retirement support complements the core medical and dental package.
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Leave & Time Off Breadth — Paid holidays and PTO that increases with tenure provide meaningful time‑off flexibility. Time‑away benefits scale with service length.
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The Company
What We Do
The Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, is a reliable name in Hawaii health care. Established in 1938, we are the largest and most experienced provider of health care coverage in the state. Over half of Hawaii’s population have chosen HMSA for their health care coverage. We are dedicated to providing quality, affordable health plans; employee benefit services; and worksite wellness programs. HMSA also offers a variety of programs, services and support to help improve the health and well-being of our members and community.
