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.