Program Integrity Analyst And Investigator

About Blue Cross
Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We're committed to reinventing health care to improve health for our members and the community. We hope you'll join us.
How is This Role Important to Our Work?
This position manages the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse and over-payment recovery cases. This includes gathering, analyzing and interpreting complex data and information to provide meaningful results in developing leads, collaboration with internal resources as well as complying with state and federal requirements for fraud, waste and abuse detection and prevention.
A Day in the Life:

• Analyze and triage referrals/leads and determine appropriate research/investigation needed with minimal guidance. Proactively identify, analyze, investigate and evaluate moderate to complex potential fraud, waste, or abuse, including pre-pay and/or post-pay medical claims reviews to determine valid cases for appropriate action; document findings, and prepares case referrals, letters, and reports.
• Conduct interviews of patients, providers, provider staff and other witness/experts.
• Represent Blue Cross by testifying at trials, offering depositions and responding to subpoenas.
• Prepare for and facilitate settlement negotiations with providers, attorneys and other responsible parties with minimal supervision.
• Document case activity, and fund allocation and conduct follow-up-actions in a timely manner following documented departmental guidelines.
• Refer well documented and substantiated cases to law enforcement agencies which may include the Federal Bureau of Investigations (FBI), the Office of the Attorney General (OIG) and local police departments.
• Meet all contractual, State and Federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS and other agencies.

Required Skills and Experiences:

• 3+ years of related professional experience. All proven experience including work, education, transferable skills, and military experience will be considered.
• 4 years of fraud, waste and abuse investigation/ loss prevention experience and experience using data analysis tools (e.g. GDIT STARS Informant, STARS Sentinel, etc.).
• Excellent demonstrated written and oral communication, interpersonal and negotiation skills to communicate with management, regulators and law enforcement.
• Proven analytic, writing and reasoning skills, including the ability to evaluate complaints, referrals and health care data laws and regulations and relevant federal laws and regulations, including but not limited to HIPAA.
• Strong organizational skills and the ability to manage and prioritize multiple investigations, projects and responsibilities.
• Ability to work independently with excellent attention to detail.
• Proficient use of Microsoft Word, Excel, PowerPoint and Visio.
• Accredited Health Insurance Fraud Investigator (AHFI) in good standing through the National Health Care Anti- Fraud Association (NHCAA) within three years of hire.

Nice to Have:

• Bachelor's Degree

Role Designation:
Hybrid Remote
Role designation definition: Teleworking is working full time remote. Hybrid is a combination of working onsite and remotely. Onsite is full-time onsite.
Make a difference
Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.
Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com.
All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.
Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.