Investigator

US-IA-Des Moines
Job ID
212787
Category
Legal/Compliance
Requires Non-Compete?
No

Job Summary

Wellmark is currently recruiting for an Investigator to join our team. Under the direction of Leadership, you will identify and investigate suspected health insurance fraud, waste and abuse, identify potential losses and recoveries for the corporation, prepare reports of suspected fraud, waste and abuse, and work with law enforcement agencies and antifraud organizations as appropriate. Investigations must be conducted in accordance with company policies and procedures and in compliance with all applicable laws and regulations.

 

If you're naturally inquisitive with prior experience investigating healthcare operations, apply today!  

Minimum Qualifications Required (all must be met to be considered)

Associate’s Degree in related field or direct and applicable work experience.

1 + years of experience:

  • In Fraud, Waste, and Abuse
  • Investigation experience
  • Strong communication skills, both verbal and written, with the ability to concisely convey your message to the appropriate audience
  • Ability to work with others in difficult and complex situations to achieve resolution or adherence to laws and/or regulations
  • Ability to prioritize workload to maximize efficiency
  • Excellent organization and decision making skills
  • Previous computer experience and strong attention to detail
  • Demonstrated ability to analyze data and make recommendations based on the data

Hiring Specifications Preferred

 

  • Prior investigation experience in the health insurance industry
  • Knowledge of billing, coding and claims processing
  • Health Care Fraud Investigator (AHFI)
  • Certified Fraud Examiner (CFE)
  • Certified Professional Coder (CPC) 

Job Accountabilities

a. Evaluate allegations of fraud and abuse from members, providers, other Plans and law enforcement by utilizing data analysis tools such as existing Business Objects reports, fraud software, and web based searches. Analyze, assemble observations and document findings to make recommendation to leadership of next steps. Maintain comprehensive case file documentation to support case.

b. Utilize fraud, waste and abuse detection software, other data sources, and leads to identify or substantiate patterns of suspected irregular health insurance activity proactively.

c. Analyze data and develop investigation plan to determine what medical records or other supporting documentation is needed and how it will be reviewed.

d. Determine if provider and/or member interviews are needed, develop script and conduct interviews.

e. Prepare letters to communicate to providers concerning decisions and provide education based on provider billing guide, medical policy and correct coding in collaboration with others departments such as health management and provider network relations.

f. Interact professionally with providers, members and other contacts both verbally and in written communication.

g. Utilize intuition and judgment based on facts uncovered in the research to determine next steps in the investigation.

h. Develop and present education to employees regarding healthcare fraud, waste and abuse issues and red flags.

i. Collaborate and investigate with the Blue Cross Blue Shield Association Strike Force by providing requested data, conducting investigation, and working cooperatively with the other Plans in support of the investigation.

j. Develop and maintain collaborative relationships with BCBSA, BCBS Plans and other antifraud professionals.

k. Other duties as assigned.

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