SIU Investigator I - Hybrid

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers 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.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

- Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week
- Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
- Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month
- Onsite: daily onsite requirement based on the essential functions of the job
- Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This position is hybrid within the state of AZ only.  This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.

PURPOSE OF THE JOB

Prevents, detects, and deters fraud, waste, and abuse involving Commercial, Government, Federal Employee Program (FEP), Medicare, and Part D programs, resulting in maximum plan value returned to the plan.

Provides the Special Investigations Unit with support for day-to-day operations, including investigations, analysis, management, and special projects.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience, All Levels

- One year of experience in healthcare-related fraud investigations and/or data mining and analysis.

Required Education, All Levels

- High school diploma or GED in a general field of study.

Required Licenses

- None.

Required Certifications

- None.

PREFERRED QUALIFICATIONS

Preferred Work Experience, All Levels

- Three to five years of experience in healthcare-related fraud investigations, data mining and analysis, and/or complex projects.

- Experience with medical coding and/or billing.

- Strong understanding of health insurance reimbursement methodologies, including working knowledge of current medical claim coding requirements, such as diagnosis and procedure codes.

Preferred Education, All Levels

- Bachelor’s degree in business, healthcare administration, accounting, nursing, criminal justice, or a related field.

Preferred Licenses

- None.

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 referrals and assess their appropriate disposition.

- Research and investigate allegations of fraud, waste, and abuse to prevent, detect, and deter inappropriate activity, resulting in maximum plan value through front-end savings, recoveries, and projected savings.

- Use resources including, but not limited to, claims-processing systems, medical coverage guidelines, payment policies, member and group benefits, and provider contracts.

- Use data-mining techniques, statistical data analysis, and analytical software to identify potential fraud, waste, and abuse involving all programs.

- Seek out and develop leads and cases received from sources including fraud alerts and government and private sources.

- Develop summary reports that explain key findings from data evaluations.

- Develop and implement corrective action plans.

- Apply critical-thinking skills and judgment during the analysis process to determine the best course of action for each tip or case.

- Escalate high-risk tips, cases, and related issues to management.

- Perform investigations such as desktop and on-site medical-record audits, surveillance, undercover work, and suspect and witness interviews.

- Prepare cases for referral to law-enforcement officials for prosecution.

- Testify and provide depositions as an expert witness in legal proceedings.

- Maintain the chain of custody for all documents and document every stage of each investigation.

- Create, update, and follow departmental operating procedures, policies, confidentiality requirements, and security guidelines.

- Develop materials and assist with fraud, waste, and abuse training for internal and external audiences.

- Attend seminars and webinars annually to remain current on fraud, waste, and abuse trends and issues.

- Participate on corporate task teams as appropriate.

LEVEL 2

- Conduct investigations and projects of greater complexity and responsibility.

- Develop report queries and evaluate data integrity to identify patterns, trends, data abnormalities, and potential schemes.

- Evaluate investigative findings.

- Provide technical support and guidance to less-experienced team members.

- Perform all responsibilities of the position with minimal supervision or training.

- Represent Corporate Integrity on teams that develop, test, and implement software and databases.

- Create and maintain reliable methods for tracking and reporting referrals, hotline calls, and fraud training.

- Perform all applicable Level 1 responsibilities.

LEVEL 3

- Serve as the primary contact for initiating and coordinating projects with other business units.
- Maintain the technical aspects of fraud-information and reporting methods, including forms, flyers, and database reporting.
- Develop, maintain, and manage the SIU case-tracking system.

- Design and generate trend-analysis reports.

- Write and understand queries used to proactively identify fraud, waste, and abuse activity in a data mart.

- Provide day-to-day support and training to the investigative team.

- Support management requests for various reporting requirements.

- Create accurate reports that satisfy internal and external reporting requirements, including Blue Cross Blue Shield Association requirements.

- Coordinate post-payment claims reviews performed by external vendors.

- Perform quality audits of closed tips and cases completed by investigators.

- Perform all applicable Level 1 and Level 2 responsibilities.

ALL LEVELS

- Each progressive level includes the ability to perform the essential functions assigned to lower levels.

- The position has an onsite expectation of 1 day per week and 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 JOB SKILLS

- Intermediate personal-computer proficiency for Levels 1 and 2.

- Advanced personal-computer proficiency for Level 3.

- Intermediate skill with word-processing, spreadsheet, and database software for Levels 1 and 2.

- Advanced skill with word-processing, spreadsheet, and database software for Level 3.

- Intermediate skill using office equipment, including copiers, fax machines, scanners, and telephones, for all levels.

- Basic knowledge of laws and regulations pertaining to insurance fraud and judicial processes related to fraud prosecutions.

- Strong ability to use social media and public websites to research allegations.

REQUIRED PROFESSIONAL COMPETENCIES, ALL LEVELS

- Maintain confidentiality and privacy.

- Prioritize, organize, and independently manage work to ensure project deadlines are met with minimal supervision.

- Manage multiple complex tips, cases, reports, projects, and other tasks, sometimes under limited time constraints.

- Apply analytical knowledge to generate reports based on data and trends and make decisions based on reported information.

- Use excellent verbal and written communication, negotiation, and interviewing skills when working with internal and external customers.

- Maintain proficiency with relevant technology, claims coding, reimbursement methodologies, company products and policies, and relevant fraud schemes.

- Demonstrate motivation and strong interpersonal skills.

- Act with diplomacy and sensitivity in adversarial situations.

- Interpret and communicate policies, procedures, programs, and guidelines.

- Establish, contribute to, and maintain positive and productive working relationships in a collaborative team environment.

- Demonstrate critical-listening and critical-thinking skills.

- Demonstrate data-analysis and trend-analysis skills.

REQUIRED LEADERSHIP EXPERIENCE AND COMPETENCIES

- None.

PREFERRED COMPETENCIES

Preferred Job Skills

- Advanced knowledge of healthcare coding, billing processes, and health insurance reimbursement for all levels.

- General knowledge of and experience using claims-processing systems.

Preferred Professional Competencies

- None.

Preferred Leadership Experience and Competencies

- None.

Our Commitment

AZ Blue 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 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.