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Pacesetter Personnel Services - Jacksonville, FL US
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Citizens Property Insurance Corporation - Jacksonville, FL US
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For your reference, we have included the original job posting below.
Specialist IIIa - Fraud
Job Number:
25549457
Company Name:
BlueCross BlueShield of Florida
Job Location:
Jacksonville, FL US
Job Category:
Insurance
Specialist IIIa - Fraud
Specialist IIIa - Fraud Requisition ID 4897 Full/Part Time Full Time Location Jacksonville, FL Miami, FL Description Posting Number: B1272JUL10 Posting Deadline: 07/22/2010
Job duties include but are not limited to the following: *Identify, investigate and evaluate potential fraud, waste or abuse to determine valid complaints/cases for appropriate action; document findings, and prepare case referrals, letters, etc *Review claims history, medical reviews, provider files, etc. and utilizes data analysis techniques to detect irregularities, billing trends, and financial relationships in BCBSF claims data to detect potential fraudulent or abusive billing practices or vulnerabilities in BCBSF, HOI or CHP policies *Conduct on site investigations at provider facilities independently or as a member of a team *Prepare documents and letters to initiate and institute administrative actions and document all activity in accordance with state practices and procedures *Lead or participate in team projects, major investigations or major cases *Act as Leader for major cases, as needed, mentors and provides education and training to team members
Job Requirements: *Bachelor's degree or equivalent work experience *5 or more years of experience in fraud investigation or a related field *Designated as a CFE or AHFI or other recognized certification in a related field *Experience with IMS, Diamond and ITS *Experience interpreting the adjudication of claims *Experience with medical review, auditing, data analysis or internal controls *Experience with CPT, ICD-9 and HCPC codes *Knowledge of BCBSF medical costs, claims, enrollment and group data *Knowledge of statistics and data analysis techniques *Certified Coder *Ability to travel *Verbal and written communication skills
Business Specific Criteria (preferred skills): *Bachelor's degree in accounting, criminology, business or other related field *Fraud investigations experience *Knowledge of state and federal laws and regulations regarding health care *Experience with Siebel application *Experience with case development and presentation of the case to an investigative, regulatory agency or corporate management *Experience with FEP, NASCO and Washington claims processing guidelines and systems *Experience with Microsoft Access *Knowledge of MHS *Bilingual in Spanish
