Associate Program Integrity Analyst/Investigator Job at Blue Cross and Blue Shield of Minnesota
About Blue Cross
Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We’re committed to reinventing health care to improve health for our members and the community. We hope you'll join us.
How Is This Role Meaningful to Our Work?
This position is responsible for the prospective and retrospective investigation of suspect claims and assisting in initial development of fraud, waste, abuse and over-payment recovery cases. This includes learning to gather, analyze and interpret data and information to provide relevant results in developing leads, collaboration with internal resources as well as complying with state and federal requirements for fraud, waste and abuse detection and prevention.
A Day in the Life:
- Analyze referrals/leads and determine what type of research/investigation is needed under close supervision.
- Assess intent and potential for fraudulent activities and/or over-payment recovery opportunities under close supervision.
- Contributes to preparations for facilitating settlement negotiations with providers, attorneys and other responsible parties with direct supervision.
- Assist with investigating cases through personal interview, analysis of claims, medical records and other available data.
- Document case activity and fund allocation and conduct follow-up-actions in a timely manner following documented departmental guidelines.
- Provide appropriate notifications to accounts as well as state and federal entities with moderate supervision.
- Assist in completing well documented and substantiated cases to law enforcement agencies which may include the Federal Bureau of Investigations (FBI), the Office of the Attorney General (OIG) and local police departments.
Required Skills and Experiences:
- 3 or more years experience in health insurance operations, or related field. All relevant experience including work, education, transferable skills, and military experience will be considered.
- 2 years of fraud, waste and abuse investigation/loss prevention experience or 3 years medical/pharmacy claims audit research and analytics or a related experience.
- Strong written and oral communication, analytical, problem resolution and negotiation skills.
- Demonstrated ability to present positive, professional behavior.
- Strong quantitative, problem-solving, and computer skills.
- Proficient use of Microsoft Office: Excel and Word .
Nice to Have:
- Bachelors degree in Health Administration, Health Care Informatics, Business Administration or related fields of study
- Knowledge of health care nomenclature and coding, programs, services, claims and fraud, waste and abuse schemes.
Role Designation:
Hybrid Remote
Role designation definition: Teleworking is working full time remote. Hybrid is a combination of working onsite and remotely. Onsite is full-time onsite.
Make a difference
Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic.
Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to talent.acquisition@bluecrossmn.com.
All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S.
Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
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