Resp & Qualifications
PURPOSE:
The role of the Special Investigations Unit (SIU) Lead Investigator is to assist in overseeing the daily operations of our Special Investigations Unit, which is responsible for investigating allegations of fraud, waste, and abuse within our health plan operations. The Lead Investigator will interact with CareFirst Investigators, law enforcement and regulators contributing to the reduction and recuperation of losses to CareFirst through 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:
- Work with CareFirst Investigators to ensure that investigations of all levels (low to complex) are carried out effectively and in a timely manner.
- Developing and executing investigative plans that may include performance 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.
- Establishing data analytic objectives and execution of data mining and analysis as an investigation technique.
- Conducting detailed offsite audits/investigations involving interviews when appropriate.
- Overseeing complex investigations and preparation of detailed reports on investigative findings for senior management and stakeholders.
- Support and oversight of other investigators to ensure audits and investigations are timely, effective and result in an overall achievement of unit goals.
- Compose formal correspondence, detailed technical reports, audit reports, spreadsheets, graphs, audit logs, anti-fraud software analysis, and appropriately sourced reference materials, and synopses that supports conclusions, recommendations, and substantiates findings. Provide complex litigation support for civil/criminal court proceedings by liaising with internal departments and external agencies, as appropriate. 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. 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.
- Support the determination of relevant analytics and key performance metrics for ongoing monitoring and reporting of investigative trends and functional performance. 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 Medicare and Medicaid requirements, 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. Establish methods for and ensure timely maintenance of case file documentation, department case management system and case updates, and preserve as potentially discoverable material. Perform special projects as assigned by management to meet the needs of the Special Investigations Unit.
QUALIFICATIONS:
Education Level: Bachelor’s Degree
Experience: 8 years 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.
Preferred Qualifications:
- Preferred credentials include Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), RN/LPN, or Certified Professional Coder (CPC).
Knowledge, Skills and Abilities (KSAs)
- Knowledge of laws that pertain to public and insurance funds.
- 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: $69,840 – $138,710
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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