Responsibilities include but are not limited to:
Provides Plan and PBM oversight for the identification, investigation, and reporting of FWA. Coordinates and facilitates single and multi-Plan investigative efforts. Conducts training as required. Participates in special projects as required. Conducts research relating to FWA and participates in the training of vendors and Plans. Assists internal/external entities with various types of litigation support. Supports various FEP SIU systems. Interacts with various areas of BCBSA regarding issues identified through investigations and reviews. Provides Plan/PBM oversight for the identification and investigation of non-compliance issues. Monitors and ensures Plan/PBM compliance with internal systems and programs. Coordinates and facilitates single and multi-Plan/PBM investigative efforts. Develops and participates in special projects as required. Lead or support various Anti-Fraud projects through the year as determined by the business.
Job Description
Required Education, Certifications and Experience
Bachelor's degree in criminal justice, healthcare, intelligence, business, compliance or related discipline or equivalent experience is required.
3 years of any of the following; fraud investigations, intelligence, business, and compliance experience.
Essential - Analyzing and responding to complex data and/or the processing of information requests.
Technical proficiency in the use of various computer software programs including Microsoft Windows, Microsoft Office (Outlook, Word, Excel, PowerPoint).
Excellent organizational and time management skills.
Analytical skills: Capability to research and analyze data/information and apply it appropriately and accurately in the resolution/response to questions/inquiries.
Strong skills in the areas of compliance and the ability to interpret written materials.
Strong interpersonal skills and relationship development abilities are essential, as well as demonstrated customer service skills.
Excellent verbal and written communication skills.
Preferred Education, Certifications and Experience
Prior federal, state, or local law enforcement experience.
Prior experience in Anti-Fraud environments in the healthcare industry.
Knowledge of federal government investigative agencies and subcontractor relationships.
Certifications
Certification as an Accredited Health Care Fraud Investigator or a Certified Fraud Examiner
People Management No
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