Resp & Qualifications
PURPOSE: To support the prevention, reduction of and/or recuperation of losses to CareFirst BlueCross BlueShield through the clinical review of medical records and claims, resulting in the savings and/or recovery of funds. Responsible for providing clinical knowledge to the SI team to support both prepayment reviews and/or post payment investigations.
PRINCIPAL ACCOUNTABILITIES: Under the direction of the assigned SI Supervisor or Manager, functions include but are not limited to:
1. Review of medical records and claims
a. Investigate potential fraud and over-utilization by performing complex medical reviews of claims and medical records. The claims may be in a pre or post payment environment.
b. Provide a detailed but concise analysis to communicate findings about the ability to pay or deny a claim or claim lines using clinical and/or coding, billing, or reimbursement knowledge.
c. Maintain appropriate records and supporting documentation regarding findings in accordance with departmental standards.
d. Process all assigned claims or batch case reviews within departmental and communicated timelines.
2. Provide support to investigative teams as they perform all levels of healthcare fraud, waste, and abuse investigations. Oral, written, and other communication skills are used to effectively accomplish the various tasks associated with case investigations including the ability to communicate technical clinical information to non-clinical individuals. Collaborate with investigative teams to correlate review findings with appropriate actions (e.g., provider education through original, complex, and technical letters, meeting and negotiating with providers, recoveries of monies, recommending network de-selection referrals to State and/or Federal Agencies to effect changes in the provider’s/facility’s practice.
3. When assigned act as liaison/consultant inside corporation on cases, in cooperation with areas such as Medical Policy, Legal and Legislative Affairs, Claims Processing Areas, Customer Service Operations, Provider Representatives, Credentialing, Contracting, Appeals and Grievances, and Utilization Management. This may include notification to above areas of problem providers/facilities, recommending changes to system edits, requesting modifications to medical policy and respective changes to on-line policy edits, and educating the above areas regarding appropriate claims processing for a particular provider/facility or service.
4. When assigned acts as liaison/consultant to agencies outside the corporation, developing cases in cooperation with Boards of Medicine, local medical societies, and State and/or Federal agencies including Office of the Inspector General, Office of Personnel Management, and Federal Bureau of Investigations. Assists outside agencies by gathering data and medical documentation for subpoenas, responds to attorney inquires and requests, and testifies in State and/or Federal courts when required. Investigates and resolves individual member inquiries and complaints related to over-utilization or potential fraud by health care providers/facilities.
5. Perform special projects to meet the objectives of the Special Investigations Unit.
Required: BS/BA degree or its equivalent in nursing and 5-10 years of nursing experience. Active RN license, Coding certification such as Certified Professional Coding (CPC) or higher.
• Background in health insurance
• Minimum of 5-10 years of clinical medical/surgical nursing experience
• Working knowledge of CPT/HCPCS coding and ICD10-CM coding
• Highly motivated, with strong drive, team spirit and organizational skills
• Excellent PC skills, including Excel, Microsoft Word, Access, and other software
• 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
• Dependable, ability to work under pressure while assuming a leadership role
• Excellent oral/written communication and interpersonal skills
• Ability to communicate technical and non-technical language to technical and non-technical persons
Preferred: Master’s degree, Certified Fraud Examiner or Accredited Health Care Fraud Investigator is desirable. In-depth knowledge of corporate and divisional policies and procedures claims processing, medical policies, underwriting enrollment and billing and other related systems and procedures.
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: 3/13/2021
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