Sr Investigator

US-IA-Des Moines
Job ID
Requires Non-Compete?

Job Summary

Wellmark is currently recruiting for a Sr 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 anti-fraud organizations as appropriate. Investigations must be conducted in accordance with company policies and procedures and in compliance with all applicable laws and regulations. You will serve as a subject matter expert by representing Wellmark at Health Care Task Force meetings and provide high-level support on various Special Investigation Unit (SIU) matters.


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

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

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

  • Certified Fraud Examiner (CFE)
  • Minimum 4 years of experience:
    • In Fraud, Waste, and Abuse
    • Healthcare investigation experience
    • In healthcare operations, including rules and regulations
  • Strong communication skills, both verbal and written, with the ability to concisely convey your message to the appropriate audience
  • Demonstrated interpersonal skills, with the ability to build relationships both internally and externally
  • Strong organization skills to prioritize workload to maximize efficiency
  • Ability to make decisions and strong attention to detail
  • Ability to deal with others in difficult and complex situations to achieve resolution or adhere to laws and regulations
  • Proficient with Microsoft Office applicatons

Hiring Specifications Preferred

  • Bachelor’s Degree in related field
  • Health Care Fraud Investigator (AHFI)
  • Certified Professional Coder (CPC) 


Job Accountabilities

a. Evaluate allegations of fraud, waste and abuse from members, providers, other Plans and law enforcement by utilizing data analysis tools such as creating new and 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 research to determine next steps in the investigation.

h. Develop and present education to employees, internal and external stakeholders regarding healthcare fraud 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. Represent Wellmark at Health Care Task Force Meetings. Support Regional Advantage Services (RAS) on SIU matters impacting IA and SD members of the Regional PDP products by collaborating, attending meetings, sharing information and providing necessary reporting.

k. Participate in projects such as data analysis tool upgrades, BlueCard changes and iCap edits by providing subject matter guidance related to SIU requirements.

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

m. Provide guidance to less experienced staff.

n. Other duties as assigned.


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