Investigator I

The Network Integrity Unit is responsible for the detection, case development and remediation in cases of suspected fraud, waste and abuse (FWA) involving commercial and government products lines. The Network Integrity department serves as the Special Investigation Unit (SIU) for the corporation and is responsible for FWA activities involving providers (i.e. facilities, physicians, and other health care providers), employer groups and members.

This position is responsible for conducting thorough and accurate investigations of potential external fraud and abuse involving commercial and government lines of business. The scope of accountability includes investigating and remediating allegations of fraud and abuse involving providers, members and employer groups. Primary activities include substantiating referrals, case research and planning, conducting onsite or desk audits, review of medical records and billing practices, interviewing potential witnesses, developing corrective action plans, developing correspondence to impacted parties, managing disputes and collaborating with law enforcement and regulatory agencies. Additional accountability includes coordination of fraud and abuse efforts with external business partners such as our Pharmacy Benefits Manager (PBM) and delegated Mental Health Benefits Manager.

FWA activities encompass cases within the Alabama service area, but will additionally involve cases outside the state that require coordination with Blue’s Plans nationwide, the national Federal Employee Program (FEP) special investigations unit as well as multiple regulatory/ investigative agencies across the country. International fraud and abuse is also inclusive of the scope when member services are rendered out of the country.

The incumbent receives referrals from many sources and determines if the allegation is substantiated before proceeding with a complete review. The incumbent performs special projects as assigned by management or other corporate areas to contribute to accomplishment of overall goals of corporation.

• Bachelor’s Degree in Healthcare, Healthcare Delivery, Legal Process, Criminal Justice or Business
• 1 year of related work experience in health insurance industry, healthcare delivery, and/or fraud, waste and abuse investigations
• Experience prioritizing multiple tasks and priorities and working under pressure when faced with multiple deadlines and last minute requests
• Understanding of healthcare concepts and the healthcare industry
• Strong oral and written communication skills and demonstrated experience in conflict and problem resolution
• Experience leading and controlling meetings containing complex information to a non-technical audience in a professional, fair, and accurate manner
• Problem solving skills and sound professional judgment to determine the appropriate course of action and follow through with minimal management assistance as needed
• Experience utilizing software programs such as Microsoft Word, Excel, PowerPoint and various data analysis applications and other applications specific to Network Integrity
• Understanding of data analytics in order to review data for patterns, trends and/or outliers
• Experience working independently and making appropriate sound decisions with oversight and direction by management preferred
• Dispute resolution and negotiation skills in order to interface appropriately with many different provider types, external agencies other Blue Plans and external business partners preferred
• Experience interacting with providers and outside regulatory agencies with management intervention preferred
• Understanding of the legal and regulatory processes as it applies to a commercial business/insurance environment preferred
• Experience interpreting laws and regulations pertinent to a case and appropriately communicating these findings to law enforcement and prosecutors preferred
• General knowledge of member and provider contract benefits, clinical guidelines, medical policy and claims processing for all lines business or equivalent healthcare related industry knowledge preferred
• Advanced Degree in Law, Criminal Justice, Business, Health related professional or Accounting preferred
• Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Certified Professional Coder (CPC), Registered Nurse (RN), Certified Pharmacy Technician (CPhT), or another healthcare professional license preferred

• Can be filled at a higher level based on experience.

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Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association