Senior Fraud Investigator

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Job Summary

BASIC FUNCTION

HCSC is looking for a dynamic individual to join its Fraud Investigations team! This position is responsible for planning and developing investigation tools and techniques to conduct detailed investigations of potentially fraudulent claim activity by members, employees and providers, both internally and externally, as well as make recommendations for prosecution, recovery and litigation. Also, reviews operational controls, and claim system controls and protocols, and recommends enhancements to reduce the potential for fraud. Incumbent performs detailed analysis of claim payment data, prepares analysis and evidentiary reports; monitors potentially fraudulent claims and suspect billing patterns along with inquiries and other business matters for HCSC and all its subsidiaries and subcontractors; and be responsible for criminal and civil case development along with the organization and preparation of cases being forwarded for prosecution or litigation. NOTE: this role is hybrid/flex and requires in-office visibility three days per week, working from home the other two days. Relocation is NOT offered; sponsorship will NOT be extended either now or in the future.

JOB REQUIREMENTS

• Bachelor’s Degree.

• Three (3) years healthcare fraud investigative experience OR 5 years law enforcement experience (local, state, or federal).

• Familiarity with laws applicable to health care fraud.

• Ability to develop effective liaison relations which facilitate case identification, investigation, and prosecution.

• Ability to independently prepare reports of interview and other documentation accurately reflecting investigative activity and results.

• Clear and concise verbal and written communication skills.

• Proficient utilization of MS suite of products (Word, Excel, PowerPoint) as well as Workday.

PREFERRED JOB REQUIREMENTS

• Certified Professional Coder

• Certified Fraud Examiner

• Accredited Health Care Fraud Investigator

• Knowledge of health care claims processing and benefits administration

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Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting .

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

Base Pay Range

$55,900.00 - $123,500.00

Exact compensation may vary based on skills, experience, and location.

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For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities.

Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren’t afraid to make innovative contributions. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Learn more about HCSC, our commitment to our members and the opportunity you’ll have to improve health care delivery in an open, collaborative environment.

HCSC is committed to diversity in the workplace and to providing equal opportunity to employees and applicants.

If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at View phone number on click.appcast.io to request reasonable accommodations.

Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "candidate home" to view your job submissions.

Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas,

Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, and Independent Licensee of the Blue Cross and Blue Shield Association

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