The primary responsibility of the Investigator is to conduct timely, thorough and accurate investigations of suspected fraud and abuse cases involving providers, subscribers, and employees and to establish the necessary relevant facts to support a management decision to seek civil action, administrative recovery, and/or criminal prosecution.
Soft Skills/Abilities • Strong people skills and the ability to be resourceful , as well as to make concise, independent and defensible decisions in often high-pressure situations
- Manage a caseload to maximize the cost effectiveness of investigative time spent.
- Investigate allegations of fraud, waste, abuse and other forms of improper activity involving providers, subscribers, and employees. Investigations may include interviews, collection of evidence, onsite visits, collaboration with internal departments and external agencies, report writing, and testifying in court proceedings.
- Research, analyze and prepare data and written reports in development of investigations.
- Utilize simple programs to extract, retrieve, compile, and analyze information from BCBSNC databases utilizing Business Objects and anti-fraud software.
- Conducts fraud and abuse awareness training for BCBSNC employees and subscribers.
- Establish and maintain working relationships with governmental law enforcement and regulatory agencies.
- Maintain continuous broad based knowledge of BCBSNC products, claims systems, benefits administration, reimbursement policies, contractual agreements of customers, membership, enrollment, and data systems.
- Maintain comprehensive knowledge of legal and investigative procedures and techniques used in the detection and prosecution of fraud and abuse cases. Requirements • Registered Nurse or a BS/BA from a 4-year college or university – preferably in business administration, health care administration, finance, accounting, nursing or criminal justice.
- 3 years experience in investigations, claims processing, appeals, or medical review Additional Critical Skills & Knowledge Needed for Job Additional Education/Experience Preferences • Knowledge of legal, investigative, and accounting procedures, data processing systems, auditing, claims processing, claims systems, medical review, appeals, membership, and enrollment is preferred
- Health care fraud investigations experience in the public or private sector a plus
- Experience with BCBSNC or another health insurance carrier is preferred
- Knowledge of BCBSNC products, claims systems, membership, enrollment, medical review, medical policies, appeals, and provider relations is preferred
Professional Certification • Certification as an Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Medical Coder is preferred
- Strong organizational skills which allow simultaneous completion of tasks and duties while maintaining the ability to coach and develop staff
- Proven ability to effectively communicate orally and in writing detailed and complex information to others that possess varying degrees of comprehension
Blue Cross Blue Shield of North Carolina - 19 months ago