Premera Blue Cross · 21 hours ago
Investigator III
Mountlake Terrace WA
Full-time
Hybrid
Mid, Senior Level
$80K/yr - $118K/yr
3+ years expPremera Blue Cross is dedicated to improving healthcare for its customers. The Investigator III role involves leading complex investigations into fraud, waste, and abuse in healthcare claims, requiring thorough analysis and collaboration with various stakeholders to ensure compliance and recover improper payments.
Cyber SecurityHealth CareInformation TechnologyInsurance
Responsibilities
Analyze healthcare claim data and vet referrals to detect fraudulent activity and independently determine the most effective and efficient method of investigation for each individual case
Perform investigative field work to include on-site office visits, record collection, and surveillance
Interview suspects and witnesses
Prepare cases, testify and give depositions to law enforcement and regulatory agencies for potential criminal prosecution
Participate in settlement negotiations with attorneys and other responsible parties
Perform root cause analysis of identified issues and prepare post-investigative reports directed towards the prevention of fraud
Make recommendations for creating SIU policies, procedures, workflows and process improvements
Develop and maintain collaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA), Blue Cross Blue Shield (BCBS) Plans, HHS OIG, other carriers' anti-fraud professionals, law enforcement and regulatory agencies
May attend webinars and conferences like BCBSA, National Health Care Anti-Fraud Association (NHCAA), and Association of Certified Fraud Examiners (ACFE) to keep apprised of developments in health care fraud
Qualification
Required
Bachelor's degree in business administration, health care administration, finance, accounting, nursing or criminal justice or (4) years of work experience in field of study
(3) years of experience in fraud investigation, special investigation unit, or a related field
Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI)
Two (2) years of active experience in auditing and investigating in the healthcare industry
Significant experience with relevant technology, such as background check systems, claims processing platforms, data mining, and fraud detection software
Demonstrated knowledge of institutional and/or professional payment methodologies
Strong understanding of health insurance reimbursement methodologies, including familiarity with International Classification of Diseases (ICD-10 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
Strong computer aptitude and experience with spreadsheet and database software, e.g., Excel, Access, Focus
Demonstrated strong technical writing skills - ability to write reports and business correspondence and to prepare case files
Ability to exercise a very high level of discretion when handling sensitive information
Benefits
Medical, vision, and dental coverage with low employee premiums.
Voluntary benefit offerings, including pet insurance for paw parents.
Life and disability insurance.
Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.
Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.
Generous paid time off to reenergize.
Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.
Employee recognition program to celebrate anniversaries, team accomplishments, and more.
Commuter perks make your trip to work less impactful on the environment and your wallet.
Free convenient on-site parking.
Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.
Company
Premera Blue Cross
Premera is a leading health plan in the Pacific Northwest, providing comprehensive health benefits and tailored services.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Jeffrey Roe
President and Chief Executive Officer
Talha Ashraf
EVP and CFO
Recent News
2025-12-04
TechTarget
2025-10-31
Company data provided by crunchbase