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Resp & Qualifications

PURPOSE:

The role of the Special Investigations Unit (SIU) Investigator is to assist in the reduction and recuperation of losses to CareFirst through the detection, investigation, and resolution of low to medium levels 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 medium) 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 report, 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.

+ Investigator researches and analyzes claims data using company anti-fraud software, Excel, and other tools to proactively identify new potential cases. Investigator will develop documentation that supports conclusions, recommendations, and substantiates findings including formal correspondence, audit reports, spreadsheets, graphs, audit logs, anti-fraud software analysis, and appropriately sourced reference materials. Investigator ensures timely maintenance and organization of case file documentation with a high level of detail and accuracy that clearly and concisely outlines investigative steps, case synopses, and findings and to preserve as potentially discoverable material.

+ 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 Preferred:

+ Certified Fraud Examiner (CFE)

+ Certified Insurance Fraud Investigator (CIFI)

+ Certified Coder (CCS or CPC)-AHIMA or AAPC

**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)

+ 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:** $53,928 - $107,107

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

SIU Commercial

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

\#LI-LY1

REQNUMBER: 21673