Job Description

Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.

Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

  • Provides the SIU with the support for day-to-day operation including triage assessment of referrals, refund recovery coordination with third party audit vendors and fraud software lead generator (StarSentinal). Create adhoc and scheduled reports and metrics for internal / external reporting requirements including BCBS Association.          


Level 1

  • Accurately triage and assess disposition of referrals using the following tools but not limited to: claims processing systems, medical coverage guidelines, payment policies, member/group benefits and provider contracts.
  • Research and interpret medical/ coding policy, procedures and guidelines and apply knowledge in order to accurately triage referrals
  • Subject matter expert in claims processing of multiple claims processing systems, adjustments and related claims issues
  • Research claims payment status to coordinate refund recoveries with third party audit vendors
  • Build and maintain close working relationships with internal stakeholders and key external client contacts (e.g. Providers, Internal Clinicians, Vendors, Customers, BCBS Association, Blue Plans, Auditors and all local, state and governments agencies
  • Escalate high risk referrals or issues to management
  • Create, update and follow standard departmental operating procedures, policies, confidentiality and security guidelines.
  • Analyze and answer questions independently
  • Participate in the procurement process
  • Participates on cross functional teams to represent the Special Investigations Unit.
  • Attend seminars / webinars to stay current on fraud, waste, and abuse trends and issues

Level 2

  • Using the StarSentinal Lead Generation tool, analyze professional, facility, pharmacy and dental models to build profiles, proactively detect schemes and perform root cause analysis on providers, members and pharmacies potentially participating in fraud, waste or abuse.  Performs data retrieval based on outlier analysis, change-score analysis, pattern analysis and rules analysis to calculate potential loss and prioritize caseload for investigators.  Validate false positive results using medical and payment policies guidelines.
  • Model financial impact analysis for trends and schemes identified
  • Compile and prepare routine accurate, timely and reliable delivery of data, reporting, analysis and metrics directed toward the prevention, detection and deterrence of fraud, waste and abuse
  • Respond to surveys and RFIs.  Prepares summary and communication reports for internal/external reporting and special projects. 
  • Generate monthly extracts for third party vendors
  • Interpret, communicate, and present results to all levels of management in consistent and easy to understand formats to facilitate fact-based decision-making
  • Participates in system maintenance, enhancements and configuration requests related to the fraud software
  • Demonstrate flexibility and adaptability toward SIU goals and objectives
  • Collaborate with peers to establish, evaluate, and continually improve measurement methodologies
  • Develop leads received from sources including fraud alerts, government and private sources
  • Create, update and follow standard departmental operating procedures, policies, confidentiality and security guidelines.
  • Participate in corporate task teams as deemed appropriate.
  • Manages current job responsibilities while taking on additional tasks
  • Requires ability to meet deadlines,quality and accuracy standards
  • Inform the manager of any issues impacting the efficient and effective performance of the department
  • Assist management and other investigators as required 
  • Demonstrates the ability to perform all responsibilities of the position with minimal need for supervision



  • Each progressive level includes the ability to perform the essential functions of any lower levels and assist / mentor employees in those levels.
  • The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
  • Perform all other duties as assigned.

BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.


  1. Required Work Experience

Level 1

  • 1 year of work experience in healthcare claims processing,  healthcare fraud investigations and/or medical coding/billing  


Level 2

  • 2 years of experience analyzing healthcare claims data
  • 2 years experience creating  and summarizing claims data reporting
  • 2 years of experience working on complex projects involving research and working with multiple business units
  1. Required Education
  • High-School Diploma or GED in general field of study (Applies to All Levels)
  1. Required Licenses
  1. Required Certifications


  1. Preferred Work Experience
  • 3 years of work experience in insurance, investigation of healthcare related fraud, medical coding and/or billing
  1. Preferred Education
    • Bachelor’s Degree in business or related field  (Applies to all Levels)
  1. Preferred Licenses
    • N/A
  1. Preferred Certifications
    • CPC, AHFI, CFE


  1. Required Job Skills (Applies to All Levels)
    • Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
    • Intermediate PC proficiency
  • Requires the ability to work with a variety of systems
  • Strong understanding of reimbursement methodologies, procedure and diagnosis codes (lev 1)
  • Knowledgeable with multiple claims processing systems (lev 1)
  • Proficient in spreadsheets and word processing software (lev 1)
  • Advanced knowledge of healthcare coding, billing processes and health insurance reimbursementAdvanced  level of understanding of multiple claims procesing systems (lev 2)
  • Advanced proficiency in spreadsheet, database and word processing software (lev 2)
  1. Required Professional Competencies (Applies to All Levels)
    • Working knowledge of HIPAA and privacy requirements
    • Maintain confidentiality 
    • Prioritize tasks while working on multiple priorities, sometimes under limited time constraints.  Organize and self-manage to ensure project deadlines are met with minimal supervision
    • Strong analytical skills to analyze, understand and research data including relevent fraud schemes
    • Strong writing skills to generate reports
    • Strong critical thinking skills to propose solutions and resolve issues
    • Strong oral communication skills to interview internal/external customers
    • Independent thinker
    • Attention to detail
    • Interpret and translate policies, procedures, products and guidelines.  Maintain proficiency with relevant technology, claims coding and reimbursement methodologies.
    • Adapt to changes, accept direction & responsibilities, support management decisions, and follow instructions
    • Motivated with strong interpersonal skills
    • Act with diplomacy and sensitivity in adversarial situations
    • Establish, contribute and maintain a positive and productive working relationship in a collaborative team environment with internal and external customers
    • Effective interpersonal skills with the ability to present and interact professionally with a diverse group, executives, managers, subject matter experts and external customers
    • Maintain a professional business appearance and demeanor that is expected when dealing with internal/external customers while representing BCBSAZ within the industry
    • Perseverance in the face of resistance or setbacks
  1. Required Leadership Experience and Competencies (Applies to All Levels)



  1. Preferred Job Skills (Applies to All Levels)
    • Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones
    • Advanced PC proficiency
    • Advanced proficiency in spreadsheet, database and word processing software
  1. Preferred Professional Competencies (Applies to All Levels)
    • Identify solutions to meet customer needs
    • Work with ambiguous and conflicting information while keeping focused on the end goal.
  1. Preferred Leadership Experience and Competencies (Applies to All Levels)
  • N/A



Application Instructions

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