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Investigator

Company: Premera Blue Cross
Location: anchorage
Posted on: May 3, 2021

Job Description:

Join Our Team: Do Meaningful Work and Improve People's 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.

To better serve our customers, we're creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

As a member of Premera's Special Investigations Unit (SIU), the Investigator II will be responsible for investigating allegations of external fraud, waste and abuse (FWA). The Investigator will initiate, analyze, develop, and successfully complete and resolve fraud investigations of medium to high level complexity. This role will perform multiple high-quality investigations concurrently and work in a collaborative environment with other SIU personnel to perform analysis and obtain analytical information of significance to support case investigations. The Investigator will coordinate efforts to recover erroneous payments made due to misrepresentative billing, fraud or another criminal act.

What you'll do:

  • Analyze healthcare claim data and vet referrals to detect fraudulent activity and independently determine the 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.
  • Interview suspects and witnesses.
  • Prepare cases, testify and 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, procedures, workflows and process improvements.
  • Develop and maintain collaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA), Blue Cross Blue Shield (BCBS) Plans, HHS OIG, other carriers' anti-fraud professionals, law enforcement and regulatory agencies.

What you'll bring:

  • Bachelor's degree or four (4) years of work experience in field of study.
  • Three (3) years of experience in fraud investigation, special investigation unit, or a related field of which includes;
  • Two (2) years of active experience in auditing and investigating in the healthcare industry.

Preferred incumbents will have

  • Registered Nurse (RN), Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI).

#LI-EK1

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What we offer

  • Medical, vision and dental coverage
  • Life and disability insurance
  • Retirement programs (401K employer match and pension plan)
  • Wellness incentives, onsite services, a discount program and more
  • Tuition assistance for undergraduate and graduate degrees
  • Generous Paid Time Off to reenergize
  • Free parking

Equal employment opportunity/affirmative action:

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.

Keywords: Premera Blue Cross, Anchorage , Investigator, Other , anchorage, Alaska

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