CareFirst Careers

Senior Audit Nurse Specialist

Resp & Qualifications

To properly and professionally investigate any allegations of fraud, waste or abuse perpetuated against the FEP program and to protect CareFirst subscribers/members, providers, vendors, company employees and FEP program members from harm, financial or otherwise, caused by fraud, waste and abuse. In addition, to seek restitution of all FEP and Company monies that have been improperly paid out to any source by the detection and investigation of highly complex and sophisticated fraud and/or abuse schemes, resulting in the savings and/or recovery of funds. 

PRINCIPAL ACCOUNTABILITIES: Under the direction of the SI Manager, functions include but are not limited to:

1. Daily review of FEP overseas medical records and claims.
a. Applies medical knowledge and clinical experience in the evaluation of provider and subscriber medical records and other documentation
b. Performs extensive research and review of the Federal Administrative Manual, BCBS Service Benefit Plan Brochure, FEP Benefit Policy, and Administrative Procedure Manual, FDA, and multiple websites;
c. Performs regular and complex fraud and/or abuse theory-approach analyses, investigations and audits of financial and business records, claims, systems reports as required;
d. Identify potential situations in which a federal employee may commit fraud or any potential situation in which federal employees is harmed or whose safety is threatened as a result of potential fraud, waste or abuse;
e. Develops documentation to substantiate findings using PC-based spreadsheets, graphics, and STARS anti-fraud software;
f. Coordinate all FEP anti-fraud and abuse initiatives and coordinate with FEP Operations and Administration;
g. Ensures that investigations and audits are timely and effective, resulting in overall achievement of the Unit’s financial recoveries target;

2. FEP Prepayment review for all pended providers.
a. Enters and updates all cases in FIMS as required; 
b. Legally documents and maintains comprehensive FEP case investigative files to preserve as potentially discoverable material; 
c. Composes formal correspondence and employs detailed technical writing in preparation of reports and synopses; 
d.   Utilizes STARS case tracking system and management systems; 
e.   Provides litigation support for civil/criminal court proceedings by collaborating with
      internal departments and external agencies;
h. Establishes and maintains liaisons with external agencies that pursue prosecution of fraud 
and/or abuse cases etc. to maintain lines of cooperation and communication:             
• The appropriate jurisdictional insurance administration fraud divisions;
• FBI, Postal Inspector, Office of the Inspector General for all Federal agencies (Department of Justice, Department of Defense, Drug Enforcement Administration, Internal Revenue Service, Secret Service, etc.);
• State licensing boards, state/local law enforcement, etc.;

3. Review and resolve all FEHBP referrals received via Lotus Routes, Inquiry Analysis Customer Services Cases (IACS), and BCBSA Anti-fraud Hotline.

4. Perform special projects to meet the needs of FEP and provide training for other employees and/or customers in recognizing potentially fraudulent and abusive acts.


QUALIFICATION REQUIREMENTS:

Required:  A four year college degree, current Licensed Practical Nurse (LPN), Registered Nurse (RN), 5-7 years of work experience in nursing, insurance, health care and/or Special Investigation Unit investigative positions, or law enforcement.

Abilities/Skills:

  • Excellent PC skills
  • Excellent oral/written communication and interpersonal skills
  • Leadership skills
  • Ability to testify before the Grand Jury and civil/criminal proceedings including the 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 customer demands
  • Ability to work effectively both independently and as a team member
  • Proven judgment, analytical, decision-making and problem-solving ability
  • Ability to interact effectively with internal and external associates at all levels
  • Dependable, with the highest level of integrity
  • Ability to work well under pressure while assuming a leadership role
  • Demonstrates a high level of sensitivity to Federal/State law


Preferred:

  • Five years of clinical or case management background
  • Certified Fraud Examiner (CFE), or Accredited Health Fraud Investigator (AHFI) certification;
  • Background in substance abuse rehabilitation and urgent care, extensive knowledge of pharmaceutical information; 
  • In-depth knowledge of CareFirst 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;


 

Department

Department:

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

Closing Date

Please apply before: 12/19/2018

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 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

Learn more about Medical Management