Resp & Qualifications
PURPOSE: To reduce and/or recuperate losses to CareFirst BlueCross BlueShield by the detection, investigation and resolution of all levels (low to complex) of fraud, waste and abuse schemes, resulting in the savings and recovery of funds.
PRINCIPAL ACCOUNTABILITIES: Under the direction of management, functions include but are not limited to:
Independently conduct low level investigations and provide support as part of an assigned team to all levels (low to complex) investigations of suspected fraud, waste, and abuse. In conjunction with assigned team or management, develop and execute investigative plans that may include performance of audits of financial business records, provider and subscriber medical data, claims, systems’ reports, medical records, analysis of contract documents, provider/subscriber claims history, benefits, external data banks and other documents to determine the possible existence of fraud and/or abuse. Provide support for offsite audits/investigations and interviews when requested. Research provider/subscriber claims activity, operations manuals, data systems, medical policies, job duties and group benefit contracts to identify control deficiencies and non-compliance. Investigator will develop documentation to substantiate findings including formal reports, spreadsheets, graphs, audit logs, use of anti-fraud software and appropriately sourced reference materials. Must ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.
Ensure timely maintenance of case file documentation, department case management system and case updates, and preserve as potentially discoverable material. Compose formal correspondence, audit reports, and case synopses.
Researches and analyzes claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases. Provide support to other team members to ensure tips receive timely review.
Initiate claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes.
Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
Required: A 4-year relevant college degree or 4 or more years of work experience in insurance, investigative, health care, nursing or law enforcement and a Certified Professional Coding (CPC) or equivalent credential.
Strong PC Skills
Excellent oral/written communication and interpersonal skills
Ability to communicate technical and non-technical language to technical and non-technical persons
Highly motivated, with strong drive, team spirit and organizational skills
Ability to prioritize multiple tasks to meet established deadlines and satisfy internal and external customers demands
Ability to work effectively both independently and as a team-member
Proven judgment, analytical, decision making, initiative, and problem-solving ability
Dependable, with the highest level of integrity
Working knowledge of medical and law enforcement terminology; knowledge of claims processing procedures, medical policies and the ability to communicate the terminology to internal and external customers.
Preferred: Credential in a health care or investigations related area such as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC). Knowledge of ICD 10 and CPT® Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry. Knowledge of corporate and divisional policies and procedures, claims processing, underwriting, medical policies, enrollment and billing and/or other related systems and procedures to determine the integrity of claims’ payments and business operations within CareFirst or previous experience in the health care industry.
Department: Post Payment Unit
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 10/26/19
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
Physical Demands: The physical demands described here are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Travel may be required between CareFirst sites and to other business-required destinations.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship