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For your reference, we have included the original job posting below.
Health Care Investigator
Job Number:
24631477
Company Name:
BlueCross and BlueShield of Massachusetts
Job Location:
Boston, MA US
Job Category:
Insurance
Health Care Investigator
Health Care Investigator Business Area: Legal Location: Boston Date Posted: Req #: bcbs-00002656
Description: Blue Cross Blue Shield of Massachusetts is an Equal Opportunity Employment/Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, or any other characteristics protected by law.
Position Summary: This position serves as an Investigator within the Fraud Investigation & Prevention Unit. This associate will demonstrate a high-level of independence in case investigation and resolution and may mentor less experienced investigators. The investigator will analyze, develop and successfully complete and resolve high-profile health care fraud investigations. He/she presents findings to health care providers and negotiates resolution of issues. The investigator will conduct timely, thorough, and accurate investigations of cases assigned to establish the relevant facts necessary to support a management decision to pursue criminal, civil, or other recovery action on the basis of fraud, waste, or abuse.
Key Accountabilities:
* Investigate cases of potential fraud and abuse, including data analysis, document review, and witness interviews.
* Prepare clear concise investigatory memoranda to support findings regarding potential fraud, waste or abuse.
* Present findings regarding overpayments to providers and/or their attorneys.
* Collaborate with Fraud Litigator to strategize on case development, presentation of findings to provider, and pursuit of legal remedies.
* Prepare cases for referral to law enforcement officials for criminal prosecution or to the relevant licensing boards.
* Appear as a witness on behalf of BCBSMA in civil and criminal proceedings.
* Provide anti-fraud training as needed to both internal and external parties. Experience and Education:
* Bachelor's degree or equivalent experience.
* Minimum of four years investigative experience in health care fraud
* Working knowledge of health insurance claims coding, including CPT and DRG coding. This is an essential requirement of the job.
* Demonstrated analytical thinking skills.
* Possesses excellent written and oral communication skills, including interviewing skills.
* Demonstrated strong organizational and prioritization skills with ability to manage multiple priorities effectively.
* Ability to use computer software to analyze data; specific skills with the STARS system a plus.
* Proficiency at intermediate level with all Microsoft Office Suite applications , including MS Word, MS Excel, and MS Access.
* Ability to effectively collaborate with key business areas.
* Valid driver's license and willingness to travel.
* AHFI, CFE, or equivalent accreditation preferred; CPC, CEMC accreditation a plus.
* Knowledge of psychiatric or pharmacy billing a plus.
