Resp & Qualifications
PURPOSE:
Reduce and/or recuperate losses to CareFirst 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.
ESSENTIAL FUNCTIONS:
- Independently conduct low to medium level investigations and provide support as part of an assigned team to all levels (low to complex) investigations of suspected fraud, waste, and abuse. In conjunction with assigned team or management, 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. Provide support for offsite audits/investigations and interviews when requested. Research 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, use of 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.
- Ensure timely maintenance of case file documentation, department case management system and case updates, and preserve as potentially discoverable material. Compose formal correspondence, audit reports, and case synopses.
- Researches and analyzes claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases. Provide support to other team members to ensure tips receive timely review.
- Initiate claim adjustments, voucher deducts, and voluntary refunds in order to recover funds. Record recoveries and savings following established processes.
- Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.
QUALIFICATIONS:
Education Level: Bachelor’s Degree OR in lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications:
- Certified Coder (CCS or CPC)-AHIMA or AAPC Preferred.
- Certified Insurance Fraud Investigator (CIFI) Preferred.
- Certified Fraud Examiner (CFE) Preferred.
Experience: 2 years insurance, investigative, health care, nursing or law enforcement.
Preferred Qualifications:
- Credential in a health care or investigations related area such as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC). Knowledge of ICD 10 and CPT® Codes, medical terminology, extensive training in claims and subscriber customer service methods, and previous experience in the health care industry.
Knowledge, Skills and Abilities (KSAs)
- Ability to analyze information gathered from investigation.
- Excellent communication skills both written and verbal.
- Ability to recognize, analyze, and solve a variety of problems.
- Ability to maintain effective interpersonal relationships.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $51,840 – $102,960
Salary Range Disclaimer
Salary will be based on education, location, experience, certifications, etc. In addition to your salary, CareFirst offers benefits such as a comprehensive benefits package, incentive and recognition programs, and 401k contribution (all benefits are subject to eligibility requirements).
Department
Special Investigations Unit
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.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
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
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