Fraud Investigator

Job Title

Fraud Investigator

Job Description Summary

As part of Blue KC's Special Investigations Unit (SIU), the Fraud Investigator conducts reviews to identify potential fraud, waste, and abuse (FWA) and claim overpayments. Assigned cases and projects are generally of moderate complexity and performed with limited oversight.

Job Description

Assist in performing ongoing FWA risk assessments, leveraging data analytics to identify trends, patterns, outliers relative to peers and clinical standards, etc. In conjunction with the Manager and/or Senior Investigator, evaluate FWA risks and prioritize for further review, based upon member health/safety and protection of plan assets.

Monitor hotlines, internal referrals, external fraud alerts (e.g., CMS, BCBSA), external healthcare anti-fraud workgroups, and other resources for potential FWA schemes.

Conduct investigations of fraud, waste and abuse in accordance with SIU policies and procedures. May work with Manager and/or Senior Investigator on larger, more complex, investigations.

Create and maintain detailed case files in accordance with SIU policies and procedures, where key investigative activities and outcomes are timely and accurately documented

Prepare detailed case reports summarizing investigative findings and recommendations. Present reports to key stakeholders (e.g., Provider Relations, Medical Management, Pharmacy, Claims, Legal)

Assist in coordinating responses to subpoenas and preparation of cases for referral to law enforcement and/or regulators.

Perform day-to-day activities for vendor-based claim overpayment recovery program (e.g., data file exchanges, proposing / reviewing new audit concepts, coordinating claim adjustments, invoices).

Assist in preparing reports for executive updates, Blue KC Audit Committee, BCBSA/FEP surveys, and other reports as needed.

Support the FWA training program for Blue KC employees and First Tier, Downstream and Related entities.

Minimum Qualifications

Bachelor's degree in criminal justice, finance, accounting, medical or other relevant academic discipline. 1 years investigative experience in the following areas (e.g., medical review, financial, medical analytics, research & adjustment, appeals) that provided the types and levels of knowledge, skills, and abilities required.

Strong communication skills with a broad range of individuals and groups (e.g., members, providers, operational areas, medical directors, provider relations, legal counsel, senior management)

Preferred Qualifications

Master's degree in criminal justice, finance, accounting, medical or other relevant academic discipline

3 years' experience conducting healthcare FWA investigations at a health insurer; experience analyzing claims data to identify FWA trends and patterns using tools such as Excel and business intelligence platforms (e.g., Power BI, Business Objects).

Knowledge of major BCBSKC business systems (e.g., Facets, ITS Host and Home) and operational processes (e.g., Claims Processing, Pharmacy, Provider Contracting/Relations, Member Services, Customer Service)

Knowledge of BCBSKC provider contracts, medical policies and member benefits

Knowledge of medical terminology and ICD/CPT coding

Experience working with the regulators (e.g., CMS, State Department of Insurance) and law enforcement (e.g., FBI, DEA, HHS-OIG, OPM-OIG and/or Department of Justice)

Juris Doctorate

Coding Certification: AAPC, AHIMA

FWA Certification: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI)

Medical License: Registered Nurse (RN), Licensed Practical Nurse (LPN), pharmacist, physician

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.