Investigator III
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Job Location:
Mountlake Terrace, WA - USA
Monthly Salary:
$ 80200 - 118300
Posted on:
Yesterday
Vacancies:
1 Vacancy
Job Summary
Workforce Classification:
HybridJoin Our Team: Do Meaningful Work and Improve Peoples Lives
Our purpose to improve customers lives by making healthcare work better is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.
Premera is committed tobeinga workplace where people feel empowered to grow innovate and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous developmentwereable to better serve our commitment that has earned us recognition as one of the best companies to work for.Learn more about our recent awards and recognitions as a greatest workplace.
Learn how Premera supports our members customers and the communities that we serve through our Healthsource blog: a member of Premeras Special Investigations Unit (SIU) theInvestigator IIIleads complex investigations into allegations of external fraud waste and abuse (FWA). This role manages mediumtohigh complexitycases from initiation through resolution producing thoroughwell documentedinvestigative reports that may be subject to legal discovery. The Investigator III conducts detailed analysis collaborates closely with SIU colleagues and balances multiple investigations this role you will also work toidentifyand recover improper payments resulting from fraudulent or misrepresentative billing while ensuring all investigative activitiescomply withcompany policies regulatory requirements and applicable laws.As anot-for-profitorganization Premera offers the opportunity to do this work with a genuine focus on doingwhatsright for our memberssupported by leaders who believe in the impact this team makes not just the metrics.
Whatyoulldo:
Analyze healthcare claim data and vet referrals to detect fraudulent activity and independentlydeterminethe most effective and efficient method of investigation for each individual case.
Perform investigative field work to include on-site office visits record collection and surveillance.
Interviewsuspects and witnesses.
Prepare casestestifyand give depositions to law enforcement and regulatory agencies for potential criminal prosecution.
Participate in settlement negotiations with attorneys and other responsible parties.
Perform root cause analysis of identified issues and prepare post-investigative reports directed towards the prevention of fraud.
Make recommendations for creating SIU policies proceduresworkflowsand process improvements.
Develop andmaintaincollaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA) Blue Cross Blue Shield (BCBS) Plans HHS OIG other carriers anti-fraud professionals lawenforcementand regulatory agencies.
May attend webinars and conferences like BCBSA National Health Care Anti-Fraud Association (NHCAA) and Association of Certified Fraud Examiners (ACFE) to keep apprised of developments in health care fraud.
Whatyoullbring:
Bachelors degree in business administration health care administration finance accountingnursingor criminal justice or(4) years of work experience in field of study.(Required)
(3) years of experience in fraud investigation special investigation unit ora relatedfield.(Required)
Certified Professional Coder (CPC) Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI).
Two (2) years of active experience in auditing and investigating in the healthcare industry.
Significant experiencewith relevant technology such as background check systems claims processing platforms data mining and fraud detection software.
Demonstrated knowledge of institutional and/or professional payment methodologies.
Strong understanding of health insurance reimbursement methodologies including familiarity with International Classification of Diseases (ICD-10 CM) Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS).
Key Skills
- Epidemiology
- Public Health
- Bank Secrecy Act
- Bioinformatics
- Fraud
- Genetics
- Interviewing
- Law Enforcement
- Qualitative Research Interviewing
- Research Experience
- Next Generation Sequencing
- Writing Skills
About Company
Premera Blue Cross is a leading health plan in the Pacific Northwest, providing comprehensive health benefits and tailored services to approximately 1.9 million people, from individuals to Fortune 100 companies. The company offers innovative health and wellness solutions focused on qu ... View more
