FWA Negotiation Specialist

Job Description

Job Description

Who we are

At Blue Cross Blue Shield Global SolutionsSM (BCBS Global SolutionsSM), we make it easy for people and organizations to access and pay for healthcare abroad. By combining digital innovation with human-centered care, we go above and beyond for our customers and deliver an international healthcare experience that’s simple, efficient, and human. Whether our customers live, work, travel or study abroad, we give them the confidence and peace of mind to embrace every journey and say “yes” to new possibilities.

We are hiring for a Fraud, Waste & Abuse Negotiation Specialist to join the team! The Fraud, Waste & Abuse (FWA) Negotiation Specialist is responsible for the day-to-day execution of our enhanced claim control strategies. The specialist is on the front line of the company's effort to reduce unnecessary medical spending and make healthcare more affordable for everyone. The primary responsibility will be to evaluate claim submissions for evidence of fraud, waste or abuse using an ever-increasing set of tools and techniques, none more important than good judgement and creative problem solving.

Responsibilities:

• Determine if claim costs are Usual, Customary and Reasonable through comparative analysis with historic claims.
• Negotiate high-cost international claims with non-contracted providers and facilities.
• Cultivate relationships with high volume providers and facilities.
• Collaborate with the Provider Relations department to identify network expansion opportunities and evaluate fee schedule proposals.
• Coordinate activities across other departments (ex. Clinical, Provider Finance, Global Service Center, Claims) and external entities (ex. home plans).
• Perform online research to fill in gaps in existing tools and understanding.
• Track activity and produce reports to measure impact and document actions.

Additional Responsibilities May Include:

• Evaluate claims and determine the most applicable and appropriate remedy for preventing fraud, waste or abuse.
• Contact external third parties through outbound call or email to obtain additional information or verify claim information.
• Validate accuracy of claim charges and initial processing decisions.
• Attempt to obtain written confirmation of falsified claims through independent investigation and recorded interviews/interrogations.
• Perform analysis on historic claims to determine the full scope of identified fraudulent activity.
• Other duties as assigned.

Requirements:

• College degree or equivalent experience required.
• Minimum 3 years of insurance industry or other relevant experience required; 5-10 preferred.
• Prior experience identifying or investigating fraud, waste and abuse is not required, but is highly valued.
• Strong working knowledge of international health insurance claims is a plus.
• Knowledge of US domestic health insurance claims is a plus.
• Strong attention to detail and problem-solving skills.
• Excellent written and verbal communication skills.
• Demonstrated ability to build relationships and negotiate positive outcomes.
• Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
• Ability to manage ambiguity and drive for resolution.
• Willingness and ability to learn and apply new skills.
• Multilingual strongly preferred.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

What you’ll get in return:

• Competitive annual salary based on experience within a similar role
• Annual bonus
• Competitive medical plans
• Telemedicine available
• Paid parental leave
• Employee assistance and wellness support 24/7
• Free international healthcare coverage

Other Great Perks:

• Hybrid work model
• Work abroad arrangements available
• Generous PTO accrual program with carry-over option
• 9 paid holidays in addition to one floating holiday and one volunteer day
• Tuition reimbursement
• Career/Learning and development opportunities
• 401(k) with generous company match
• Pet insurance offerings
• Identity theft and legal coverages available
• Emphasis on well-being (Virtual well-being platform, monthly mindfulness events, and giveaways)