Clinical Program Integrity Investigator (Behavioral Health)
University of Minnesota School of Nursing
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Descripción de la vacante
Blue Cross and Blue Shield of Minnesota is seeking a Program Integrity Analyst/Investigator Clinical - Behavioral Health to investigate suspect claims and develop recovery cases. You will analyze data, gather information, and collaborate with internal resources while complying with state and federal requirements.
The role requires 3+ years in healthcare investigations, a bachelor's degree, and MN licensure as a nurse or licensed behavioral health clinician.
Formación
- 3+ years of healthcare operations auditing/investigations experience.
- Bachelor's degree required; additional two years may substitute for degree.
- Ability to travel during workday and overnight travel.
Responsabilidades
- Analyze and triage referrals to determine investigation needs with minimal guidance.
- Investigate and document moderate to complex potential fraud, waste, or abuse, including pre-/post-pay review.
- Conduct interviews with patients, providers, staff, and other witnesses.
- Review medical records for appropriateness using clinical expertise and claims data.
- Represent the organization in trials, depositions, and subpoenas as needed.
- Prepare case referrals, letters, and reports with clear findings.
Conocimientos
Educación
Descripción del empleo
Blue Cross and Blue Shield of Minnesota is seeking a Program Integrity Analyst/Investigator Clinical - Behavioral Health to investigate suspect claims and develop recovery cases. You will analyze data, gather information, and collaborate with internal resources while complying with state and federal requirements.
The role requires 3+ years in healthcare investigations, a bachelor's degree, and MN licensure as a nurse or licensed behavioral health clinician.
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