Resp & Qualifications
- The role of the Special Investigations Unit (SIU) Investigator, Sr. is to assist in the reduction and recuperation of losses to CareFirst through 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.
- Independently or as lead in part of an assigned team develop and conduct healthcare fraud, waste, and abuse investigations of all levels (low to complex). 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. Conducting detailed offsite audits/investigations with interviews when appropriate. Researching 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, 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.
- Senior Investigator will develop documentation that supports conclusions, recommendations, and substantiates findings including formal correspondence, audit reports, spreadsheets, graphs, audit logs, anti-fraud software analysis, and appropriately sourced reference materials. Investigator ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps, case synopses, and findings and to preserve as potentially discoverable material. Provide complex litigation support for civil/criminal court proceedings by collaborating with internal departments/external agencies. Establish and use liaisons with the appropriate Insurance Administration Fraud division, FBI, Postal Inspector, OIG for all Federal agencies, DOJ, DOD, DEA, state licensing boards, state/local law enforcement, etc. to maintain lines of cooperation/communication with external agencies that pursue prosecution of fraud and/or abuse cases.
- Perform root cause analysis on cases to identify problems and make recommendations to management, as they relate to risk mitigation and effective external/internal controls for CareFirst Business Operations.
- Initiates claim adjustments, court ordered restitution, settlement agreements, promissory notes, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes. Interpret standard State/Federal criminal statutes and criminal and civil law impacting insurance fraud/abuse investigations to preserve the integrity of the investigation and to report possible effects on corporate risk issues, policies, and procedures.
- Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
Education Level: Bachelor's Degree.
Certified Insurance Fraud Investigator (CIFI).
Certified Expert Coder-AHIMA or AAPC.
Experience: 5 years of work experience in insurance, investigative field, health care, nursing or law enforcement, at least 3 of which must be health care specific and includes independently conducting healthcare fraud, waste, and abuse investigations of all levels.
Knowledge, Skills and Abilities (KSAs)
- Knowledge of laws that pertain to public and insurance funds.
- Excellent communication skills both written and verbal.
- Ability to recognize, analyze, and solve a variety of problems.
- Ability to maintain effective interpersonal relationships.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $64,296 - $127,699
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Special Investigations 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.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
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.
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 up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship