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:
1. 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.
2. Ensure timely maintenance of case file documentation, department case management system and case updates, and preserve as potentially discoverable material. Compose formal correspondence and detailed technical reports and synopses. 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.
3. Provide leadership, guidance, investigative plan approval, and quality review for other investigators. Provide training to Level I and II investigators as directed to support development.
4. 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.
5. 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.
6. Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
Required: A 4-year relevant college degree or equivalent, and 5 or more 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.
A Certified Professional Coder (CPC) or equivalent, and at least one additional credential in a health care or investigations related area such as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or additional coding certifications.
• Medicare Advantage
• Excellent 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
• Effectively interact 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
• Demonstrate ability to comprehend Federal/State law, and coding manuals and
• Ability to further knowledge with additional education
Preferred: In depth 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 other health care organization.
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: 2.5.2021
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