Program Integrity Analyst/Investigator Clinical - Behavioral Health
Council of State and Territorial Epidemiologists, Eagan, MN, United States
Description
At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life.
About Blue Cross and Blue Shield of Minnesota
Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an affirmative action plan as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to any legally protected characteristic.
The Impact You Will Have
In this position, you will be responsible for the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse, and over‑payment recovery cases. This includes gathering, analyzing, and interpreting complex data and information to provide meaningful results, developing leads, collaborating with internal resources, and complying with state and federal requirements for fraud, waste, and abuse detection and prevention.
Your Responsibilities
Analyze and triage referrals/leads and determine appropriate research and investigation needed with minimal guidance.
Proactively identify, analyze, investigate, and evaluate moderate to complex potential fraud, waste, or abuse, including pre‑pay and/or post‑pay medical claims reviews to determine valid cases for appropriate action; document findings and prepare case referrals, letters, and reports.
Conduct interviews of patients, providers, provider staff, and other witness/experts.
Utilize clinical expertise, health plan knowledge, and claims analysis to review and assess medical records for appropriateness.
Represent Blue Cross by testifying at trials, offering depositions, and responding to subpoenas.
Prepare for and facilitate settlement negotiations with providers, attorneys, and other responsible parties with minimal supervision.
Document case activity, fund allocation, and conduct follow‑up actions in a timely manner following documented departmental guidelines.
Refer well documented and substantiated cases to law enforcement agencies, which may include the Federal Bureau of Investigation (FBI), the Office of the Attorney General (OIG), and local police departments.
Meet all contractual, state, and federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS, and other agencies.
Required Skills and Experience
Registered nurse or licensed behavioral health clinician (e.g., LICSW, LPCC, LMFT, LP, LADC, LBS, BCBA) with current MN license and no restrictions or pending restrictions.
3+ years of related professional clinical experience.
4 years of fraud, waste, and abuse investigation/loss prevention experience and experience using data analysis tools (e.g., Healthcare Fraud Shield).
Excellent written and oral communication, interpersonal, and negotiation skills to communicate with management, regulators, and law enforcement.
Proven analytic, writing, and reasoning skills, including the ability to evaluate complaints, referrals, and healthcare data laws and regulations and relevant federal laws and regulations, including but not limited to HIPAA.
Strong organizational skills and the ability to manage and prioritize multiple investigations, projects, and responsibilities.
Ability to work independently with excellent attention to detail.
Proficient use of Microsoft Word, Excel, PowerPoint, and Visio.
Accredited Health Insurance Fraud Investigator (AHFI) in good standing through the National Health Care Anti‑Fraud Association (NHCAA) within five years of hire.
Requires the ability to travel during the workday and potential overnight travel.
Required to have and maintain a valid driver's license and auto insurance or access to reliable transportation.
High school diploma (or equivalency) and legal authorization to work in the U.S.
Preferred Skills and Experience
Bachelor's Degree
Compensation and Benefits
Pay Range: $68,900.00 – $91,300.00 – $113,700.00 Annually.
Benefits include medical, dental, vision insurance; life insurance; 401k; paid time off (PTO); volunteer paid time off (VPTO); and more.
Equal Employment Opportunity Statement
Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talent.acquisition@bluecrossmn.com.
#J-18808-Ljbffr
At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life.
About Blue Cross and Blue Shield of Minnesota
Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an affirmative action plan as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to any legally protected characteristic.
The Impact You Will Have
In this position, you will be responsible for the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse, and over‑payment recovery cases. This includes gathering, analyzing, and interpreting complex data and information to provide meaningful results, developing leads, collaborating with internal resources, and complying with state and federal requirements for fraud, waste, and abuse detection and prevention.
Your Responsibilities
Analyze and triage referrals/leads and determine appropriate research and investigation needed with minimal guidance.
Proactively identify, analyze, investigate, and evaluate moderate to complex potential fraud, waste, or abuse, including pre‑pay and/or post‑pay medical claims reviews to determine valid cases for appropriate action; document findings and prepare case referrals, letters, and reports.
Conduct interviews of patients, providers, provider staff, and other witness/experts.
Utilize clinical expertise, health plan knowledge, and claims analysis to review and assess medical records for appropriateness.
Represent Blue Cross by testifying at trials, offering depositions, and responding to subpoenas.
Prepare for and facilitate settlement negotiations with providers, attorneys, and other responsible parties with minimal supervision.
Document case activity, fund allocation, and conduct follow‑up actions in a timely manner following documented departmental guidelines.
Refer well documented and substantiated cases to law enforcement agencies, which may include the Federal Bureau of Investigation (FBI), the Office of the Attorney General (OIG), and local police departments.
Meet all contractual, state, and federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS, and other agencies.
Required Skills and Experience
Registered nurse or licensed behavioral health clinician (e.g., LICSW, LPCC, LMFT, LP, LADC, LBS, BCBA) with current MN license and no restrictions or pending restrictions.
3+ years of related professional clinical experience.
4 years of fraud, waste, and abuse investigation/loss prevention experience and experience using data analysis tools (e.g., Healthcare Fraud Shield).
Excellent written and oral communication, interpersonal, and negotiation skills to communicate with management, regulators, and law enforcement.
Proven analytic, writing, and reasoning skills, including the ability to evaluate complaints, referrals, and healthcare data laws and regulations and relevant federal laws and regulations, including but not limited to HIPAA.
Strong organizational skills and the ability to manage and prioritize multiple investigations, projects, and responsibilities.
Ability to work independently with excellent attention to detail.
Proficient use of Microsoft Word, Excel, PowerPoint, and Visio.
Accredited Health Insurance Fraud Investigator (AHFI) in good standing through the National Health Care Anti‑Fraud Association (NHCAA) within five years of hire.
Requires the ability to travel during the workday and potential overnight travel.
Required to have and maintain a valid driver's license and auto insurance or access to reliable transportation.
High school diploma (or equivalency) and legal authorization to work in the U.S.
Preferred Skills and Experience
Bachelor's Degree
Compensation and Benefits
Pay Range: $68,900.00 – $91,300.00 – $113,700.00 Annually.
Benefits include medical, dental, vision insurance; life insurance; 401k; paid time off (PTO); volunteer paid time off (VPTO); and more.
Equal Employment Opportunity Statement
Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talent.acquisition@bluecrossmn.com.
#J-18808-Ljbffr