We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.
Residency in or relocation to Louisiana is preferred for all positions.
POSITION PURPOSE
Responsible for conducting and leading internal and external investigations for designated lines of business (Commercial, OGB, FEP, ITS, Medicare Advantage, Vantage, etc.), to ensure payment integrity within the respective programs. Provides management with insights and recommendations to, deter, detect, prevent and recover losses due to fraud, waste, and abuse. Accountable for complying with all laws and regulations that are associated with duties and responsibilities.
NATURE AND SCOPE
This role does not manage people
This role reports to this job: Manager, Special Investigations
Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with:Employees at all levels. Providers, subscribers, group leaders, external consultants, attorneys, external auditors, governmental agencies, all levels of prosecutorial agencies, other Blue Plans, and agencies/businesses as needed.
QUALIFICATIONS
Education
Bachelor's in Audit, Accounting, Criminal Justice, Nursing or another related field as deemed necessary by department management is required.
Four years of related experience can be used in lieu of a Bachelor's degree.
Work Experience
3 years experience in a predominantly analytical position related to fraud investigations, audits, medical procedures or coding. required
Skills and Abilities
Excellent communication, negotiation, and interrogation skills. Must be capable of taking the lead in interviews with witnesses, suspects, and/or their attorneys.
Ability to manage time, cases, and partner with assigned analyst(s) to determine plan of action and assign specific tasks to be completed in relation to the case on a daily basis.
Ability to travel 20% to 40% of time in order to conduct Provider/Subscriber on-site reviews and face-to-face meetings for assigned cases. Travel is largely in state; however, national travel, as well as some overnight travel, is also required.
Ability to conduct interviews in which 70% of interviews are face-to-face in order to assess body language of interviewees.
Must have proficient computer skills, including knowledge of Microsoft programs.
Licenses and Certifications
Requires an approved certification or medical license such as CIA, CPA, CFE, CISA, POST, RN, LPN or other business or clinical licensures as approved by department management.
Non Clinical\AZDL - Driver Licence - Valid And In State Good driving record as well as use of an automobile that is properly licensed and insured pursuant to all legal requirements.
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS
Deter, detect, and investigate fraudulent and abusive activity and independently decide the most effective and efficient method of investigation for each individual case.
Manage a full caseload - perform multiple high-quality investigations concurrently by prioritizing work and delegating activities to Analysts and other team members if necessary.
Gather and analyze data and information from internal and external sources - including claims history databases, public record information systems, other insurance carriers, and law enforcement officers.
Collect and preserve detailed evidence.
Prepare cases for referral to law enforcement and regulatory agencies.
Testify and give depositions on behalf of Company as a witness in legal proceedings with appropriate oversight.
Document all stages of each investigation using Company and department procedures, templates, and forms.
Prepare post-investigative reports directed towards the prevention of fraud through the identification of root-cause problems and issues in the Company's claims payment systems, contracts, policies and procedures.
Handle highly confidential and sensitive information while ensuring compliance with the Company's privacy policies.
Participate on special projects, committees, and task forces as requested by management.
Reduce or eliminate Medicare Part C and D benefit costs due to fraud, waste, and abuse.
Reduce or eliminate fraudulent and abusive claims paid for with federal dollars.
Refer suspected, detected, or reported cases of illegal drug activity, including drug diversion, to Centers for Medicare & Medicaid Services' National Benefit Integrity Medicare Drug Integrity Contractors (NBI MEDIC) and/or law enforcement and conduct case development and support activities for the NBI MEDIC and law enforcement.
Assist law enforcement by providing information necessary for legal action as requested by management.
Additional Accountabilities and Essential Functions
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
Perform other job-related duties as assigned, within your scope of responsibilities.
Job duties are performed in a normal and clean office environment with normal noise levels.
Work is predominately done while standing or sitting.
The ability to comprehend, document, calculate, visualize, and analyze are required.
An Equal Opportunity Employer
All BCBSLA EMPLOYEES please apply through Workday Careers.
PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
Additional Information
Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.
JOB CATEGORY: Legal, Compliance & Audit
