Blue Cross and Blue Shield of Minnesota · 12 hours ago
Program Integrity Analyst/Investigator Clinical - Behavioral Health
Eagan, MN
Full-time
Hybrid
Mid, Senior Level
$69K/yr - $114K/yr
4+ years expBlue Cross and Blue Shield of Minnesota is committed to transforming healthcare and is seeking a Program Integrity Analyst/Investigator in the Behavioral Health domain. The role involves investigating suspect claims, analyzing complex data, and ensuring compliance with fraud detection and prevention regulations.
Insurance
Responsibilities
Analyze and triage referrals/leads and determine appropriate research/investigation needed with minimal guidance. Proactively identify, analyze, investigate and evaluate moderate to complex potential fraud, waste, or abuse, including pre- pay and/or post-pay medical claims reviews to determine valid cases for appropriate action; document findings, and prepares case referrals, letters, and reports
Conduct interviews of patients, providers, provider staff and other witness/experts
Utilize clinical expertise, health plan knowledge, and claims analysis to review and assess medical records for appropriateness
Represent Blue Cross by testifying at trials, offering depositions and responding to subpoenas
Prepare for and facilitate settlement negotiations with providers, attorneys and other responsible parties with minimal supervision
Document case activity, and fund allocation and conduct follow-up-actions in a timely manner following documented departmental guidelines
Refer well documented and substantiated cases to law enforcement agencies which may include the Federal Bureau of Investigations (FBI), the Office of the Attorney General (OIG) and local police departments
Meet all contractual, State and Federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS and other agencies
Qualification
Required
Registered nurse or licensed behavioral health clinician (i.e. LICSW, LPCC, LMFT, LP, LADC, LBS, BCBA) with current MN license and no restrictions or pending restrictions
3+ years of related professional clinical experience. All relevant experience including work, education, transferable skills, and military experience will be considered
4 years of fraud, waste and abuse investigation/ loss prevention experience and experience using data analysis tools (e.g. Healthcare Fraud Shield, etc.)
Excellent demonstrated written and oral communication, interpersonal and negotiation skills to communicate with management, regulators and law enforcement
Proven analytic, writing and reasoning skills, including the ability to evaluate complaints, referrals and health care data laws and regulations and relevant federal laws and regulations, including but not limited to HIPAA
Strong organizational skills and the ability to manage and prioritize multiple investigations, projects and responsibilities
Ability to work independently with excellent attention to detail
Proficient use of Microsoft Word, Excel, PowerPoint and Visio
Accredited Health Insurance Fraud Investigator (AHFI) in good standing through the National Health Care Anti-Fraud Association (NHCAA) within five years of hire
This role requires the ability to travel during the workday and potential overnight travel
Required to have and maintain a valid driver's license and auto insurance or access to reliable transportation
High school diploma (or equivalency) and legal authorization to work in the U.S
Preferred
Bachelor's Degree
Benefits
Medical, dental, and vision insurance
Life insurance
401k
Paid Time Off (PTO)
Volunteer Paid Time Off (VPTO)
And more
Company
Blue Cross and Blue Shield of Minnesota
About Blue Cross Blue Cross and Blue Shield of Minnesota is a taxable, nonprofit organization with a mission to make a healthy difference in people’s lives.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Carrie S. Lawrence
Executive Administrator to the President & CEO and Chief of Staff
Patsy Riley
Chief Goverment Officer and Senior Vice President and CEO, ClearStone Solutions
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