Healthcare Investigator

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As a member of Premera’s Special Investigations Unit (SIU), the Investigator III leads complex investigations into allegations of external fraud, waste, and abuse (FWA). This role manages medium to ‑high complexity cases from initiation through resolution, producing thorough, ‑well documented investigative reports that may be subject to legal discovery. The Investigator III conducts detailed analysis, collaborates closely with SIU colleagues, and balances multiple investigations simultaneously. In this role, you will also work to identify and recover improper payments resulting from fraudulent or misrepresentative billing, while ensuring all investigative activities comply with‑ company policies, regulatory requirements, and applicable laws. What you’ll do: Analyze healthcare claim data and vet referrals to detect fraudulent activity and independently determine the most effective and efficient method of investigation for each individual case.

Perform investigative field work to include on‑site office visits, record collection, and surveillance.

Prepare cases, testify and give depositions to law enforcement and regulatory agencies for potential criminal prosecution.

Perform root cause analysis of identified issues and prepare post‑investigative reports directed towards the prevention of fraud.

Make recommendations for creating SIU policies, procedures, workflows and process improvements.

Develop and maintain collaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA), Blue Cross Blue Shield (BCBS) Plans, HHS OIG, other carriers' anti‑fraud professionals, law enforcement and regulatory agencies.

May attend webinars and conferences like BCBSA, National Health Care Anti‑Fraud Association (NHCAA), and Association of Certified Fraud Examiners (ACFE) to keep apprised of developments in health care fraud.

Bachelor’s degree in business administration, health care administration, finance, accounting, nursing or criminal justice or (4) years of work experience in field of study. (3) years of experience in fraud investigation, special investigation unit, or a related field. (Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI). (2) years of active experience in auditing and investigating in the healthcare industry. (Significant experience with relevant technology, such as background check systems, claims processing platforms, data mining, and fraud detection software.

Strong understanding of health insurance reimbursement methodologies, including familiarity with International Classification of Diseases (ICD‑10 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS).

Strong computer aptitude and experience with spreadsheet and database software, e.g., Excel, Access, Focus.

Demonstrated strong technical writing skills - ability to write reports and business correspondence and to prepare case files.

Premera total rewards Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

Medical, vision, and dental coverage with low employee premiums.

Life and disability insurance.

Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.

We have tuition assistance for both undergraduate and graduate degrees.

For our hybrid employees, our on‑campus model provides flexibility to create your own routine with access to on‑site resources, networking opportunities, and team engagement.

Free convenient on‑site parking.

Participate in engaging on‑site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.

Our complementary fitness & well‑being center offers both in‑person and virtual workouts and nutritional counseling.

Challenge someone to a game of shuffleboard or ping pong while on campus.

Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at View email address on click.appcast.io or via phone at View phone number on click.appcast.io.

we generally target up to and around the midpoint of the range.