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.

Internal use only-Grade 27-29

Prevents, detects, and deters fraud, waste, and abuse against Commercial, Government (FEP and Medicare) and Part D Programs, resulting in maximum plan value returned back to plan.   Provides the SIU with support for day-to-day operations including investigations, analysis, management, and special projects.

REQUIRED QUALIFICATIONS

Required Work Experience (All Levels)

  • 1 year of experience in healthcare related fraud investigations, and / or data mining/analysis

Required Education (All Levels)

  • High School Diploma or GED in general field of study

Required Licenses

  • N/A

Required Certifications

  • N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience  (All Levels)
  • 3 -5 years(s) of experience in healthcare related fraud investigations, data mining/analysis and/or complex projects
  • Medical coding and/or billing
  • Strong understanding of health insurance reimbursement methodologies, including working knowledge  of current medical claim coding requirements (i.e., diagnosis and procedure codes)

Preferred Education  (All Levels)

  • Bachelor’s Degree in business, healthcare administration, accounting, nursing, criminal justice or related field

Preferred Licenses

  • N/A
Preferred Certifications
  • Accredited Health Care Fraud Investigator (AHFI)
  • Certified Fraud Examiner (CFE)
  • Certified Professional Coder (CPC)
  • Certificates/designations and/or advanced training in healthcare fraud and abuse investigations
 

ESSENTIAL job functions AND RESPONSIBILITIES

Level 1

  • Accurately triage and assess disposition of referrals.
  • Research and investigate allegations of fraud, waste and abuse to prevent, detect and deter resulting in maximum plan value (front-end savings, recoveries, projected savings) returned back to plan; using the following tools but not limited to, claims processing systems, medical coverage guidelines, payment policies and member/group benefits and provider contracts. 
  • Utilize data mining techniques, statistical data analysis, and analytical software to identify potential fraud, waste, and abuse against all Programs.
  • Seek out and develops leads and cases received from sources including fraud alerts, government and private sources.
  • Develop summary reports that explain key findings in data evaluation.   
  • Develop and implement corrective action plans
  • Incorporate critical thinking skills and judgment in analysis process to determine best course of action for each tip/case.
  • Escalate high risk and/or tip & case issues to management
  • Perform investigations, such desk top and on-site medical record audits, surveillance, undercover work, suspect & witness interview.
  • Prepare cases for referral to law enforcement officials for prosecution
  • Testify and give depositions as an expert witness in legal proceedings.
  • Maintain chain of custody on all documents, documenting all stages of each investigation.
  • Create, update and follow standard departmental operating procedures, policies, confidentiality and security guidelines.
  • Develop materials and assist with fraud, waste, and abuse training for internal and external audiences.
  • Attend seminars / webinars annually to stay current on fraud, waste, and abuse trends and issues.
  • Participate in corporate task teams as deemed appropriate.

Level 2

  • Work on investigations and projects of greater complexity and responsibility by developing report queries and evaluate data integrity to identify patterns and trends and data aberrancies/schemes to evaluate investigative findings. 
  • Provide technical support and guidance to less experienced team members.
  • Perform all responsibilities of the position with minimal need for supervision or training.
  • Represent Corporate Integrity on teams to develop, test and implement software, databases or to create and maintain other reliable method of tracking and reporting referrals, hotline calls and fraud training.

Level 3

  • Act as primary contact for initiating and coordinating projects with other business units.
  • Maintain technical aspects of fraud information/reporting methods (e.g.: forms, flyers and database reporting).
  • Develop, maintain and manage SIU case tracking system and design and generate trend analysis reports.
  • Write and understand queries to pull fraud waste and abuse activity proactively from a data mart.
  • Provide day-to-day support and training to investigative team.
  • Support management requests for various reporting requirements.
  • Create accurate reports for internal / external reporting requirements, including BCBSA.
  • Coordinate post-payment claims review by external vendors.
  • Perform quality audits of closed tip and cases work from Investigators.

ALL Levels

  • Each progressive level includes the ability to perform the essential functions of any lower 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.

competencies

REQUIRED COMPETENCIES

Required Job Skills

  • Intermediate PC proficiency (Level 1-2)
  • Advanced PC proficiency (Level 3)
  • Intermediate PC skills in word processing, spreadsheet and database software (level 1-2)
  • Advanced PC skills in word processing, spreadsheet and database software (level 3)
  • Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones (All Levels)
  • Basic knowledge of regulations and laws pertaining to insurance fraud and judicial processes relating to fraud prosecutions (All Levels)
  • Strong use of social media and public sites to research allegations

Required Professional Competencies for all Levels

  • Maintain confidentiality and privacy
  • Prioritize, organize and self-manage to ensure project deadlines are met with minimal supervision
  • Multitask complex tips and cases, reports, projects and other tasks as required by BCBSAZ or mandates, sometimes under limited time constraints.
  • Analytical knowledge necessary to generate reports based on data and trending and then make decisions based on reported data
  • Use excellent oral / written communication skills, negotiation, and interviewing skills with internal /external customers.
  • Maintain proficiency with relevant technology, claims coding and reimbursement methodologies and  BCBSAZ products and policies and relevant fraud schemes.
  • Motivated with strong interpersonal skills.
  • Act with diplomacy and sensitivity in adversarial situation
  • Interpret and translate policies, procedures programs and guidelines .
  • Establish, contribute and maintain a positive and productive working relationship in a collaborative team environment with internal and external customers.
  • Critical listening and thinking skills.
  • Data analysis and trending skills.

Required Leadership Experience and Competencies

  • N/A

Our Commitment

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.

Thank You

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.


Imagine doing life-changing work and helping more than one million Arizonans live healthier and longer lives. That’s the kind of satisfaction you’ll find when you work here. Our exceptional teams in Phoenix, Tucson, Chandler, and Flagstaff have been transforming healthcare for more than 80 years. Explore what's possible with a career at Blue Cross® BlueShield® of Arizona



Posted 24 Days Ago

Full time

R1140

Application Instructions

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