Fraud Investigator

Blue Cross & Blue Shield of Rhode Island; United States; Hybrid; USD 66,000 - 98,000; Full time

Benefits offered by this job

Hybrid/Remote work options

CPC designation

Job summary

Blue Cross & Blue Shield of Rhode Island is seeking a detail-oriented Fraud Investigator to respond to reports of potential fraud and conduct thorough investigations involving members, providers, and accounts. You will analyze diverse data sources, apply regulatory requirements, and document findings to support resolutions.

The role requires 3–5 years of relevant experience and professional designations (AHFI or CFE preferred, must obtain if not held).

Qualifications

• Bachelor's degree in Business Administration or related field or equivalent experience.
• Three to five years experience interpreting health care and claims payment information or performing audits.
• AHFI or CFE designation (or must obtain within employment).
• Knowledge of fraud investigational techniques and state/federal fraud regulations.

Responsibilities

• Respond to reports of potential fraud and abuse.
• Conduct investigations of fraudulent and abusive activities involving members, providers, and accounts.
• Analyze enrollment data, contracts, financials, and claims history to identify fraud patterns.
• Apply regulatory and contractual requirements to investigations.
• Perform data analysis and SAS Fraud Framework reviews to spot trends and anomalies.

Skills

Fraud investigation

Data analysis

Regulatory knowledge

Communication

Presentation

Problem solving

Organizational skills

Negotiation

Education

Bachelor's degree in Business Administration or related field

Job description

Pay Range: $65,600.00 - $98,400.00

Please email [e-mail] if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

At BCBSRI, our greatest resource is our people. We come from varying backgrounds, different cultures, and unique experiences. We are hard-working, caring, and creative individuals who collaborate, support one another, and grow together. Passion, empathy, and understanding are at the forefront of everything we do-not just for our members, but for our employees as well. We recognize that to do your best work, you have to be your best self.

It's why we offer flexible work arrangements that include remote and hybrid opportunities and paid time off. We provide tuition reimbursement and assist with student-loan repayment. We offer health, dental, and vision insurance as well as programs that support your mental health and well-being. We pay competitively, offer bonuses and investment plans, and are committed to growing and developing our employees. Our culture is one of belonging. We strive to be transparent and accountable. We believe in equipping our associates with the knowledge and resources they need to be successful. No matter where you're at in the organization, you're an integral part of our team and your input, thoughts, and ideas are valued. Join others who value a workplace for all. We appreciate and celebrate everything that makes us unique, from personal characteristics to past experiences. Our different perspectives strengthen us as an organization and help us better serve all Rhode Islanders. We're dedicated to serving Rhode Islanders. Our focus extends beyond providing access to high-quality, affordable, and equitable care. To further improve the health and well-being of our fellow Rhode Islanders, we regularly roll up our sleeves and get to work (literally) in communities all across the state-building homes, working in food pantries, revitalizing community centers, and transforming outdoor spaces for children and adults. Because we believe it is our collective responsibility to uplift our fellow Rhode Islanders when and where we can, our associates receive additional paid time to volunteer.

Why this job matters:

• Respond to reports of potential provider or member fraud and abuse cases.
• Conduct the investigation of fraudulent and abusive activities involving members, providers, and accounts within the organization.
• Ensure adherence to corporate and regulatory statutes.
• Identify claims patterns and behavior illustrating possible fraudulent practices and/or billing abuses.

What you will do:

• Respond to all reports of potential fraud and abuse.
• Conduct the investigation of fraudulent and abusive activities involving members, providers, and accounts within the organization.
• Analyze enrollment data, contract terms, financial records, provider and subscriber claims history, and other documentation to determine fraud or abuse and identify potential patterns.
• Apply regulatory and contractual requirements as well as internal policies and procedures to the case investigation process.
• Perform data analysis, research and review of claims data and SAS Fraud Framework to identify trends, patterns, outliers and emerging issues in healthcare fraud, waste, and abuse.
• Conduct audits and interviews to provide additional investigation.
• Maintain the integrity of documentation for fraud and abuse cases.
• Update fraud database to ensure documentation of all calls, referrals, and inquiries for records keeping purposes.
• Establish and maintain strong relationships with external agencies including the Department of Health, Office of Inspector General, Pharmacy Benefit Manager, Federal Drug Enforcement, OPM, RI Attorney General, US Attorney General and state/local law enforcement.
• Preparing data requests from external law enforcement agencies listed above.
• Write clear and concise reports, present findings to health care providers, and participate in negotiated resolution of issues at the direction of SIU management.
• Track and report any claim adjustments, settlement agreements, or payment plan agreements determined as result of investigation or court ordered restitution.
• Attend training as required in response to regulator and company requirements.
• Assist with providing fraud prevention training to associates and external customers.
• Participate in department initiatives and projects.
• Perform other duties as assigned.

What you need to succeed:

• Bachelor's degree in Business Administration or related field, or an equivalent combination of education and experience
• Three to five years experience with the interpretation of health care and claims payment information or audit activities
• Accredited Health Care Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) designations or must obtain within employment
• Knowledge of fraud investigational techniques and both state and federal regulations and statutes regarding fraud, waste and abuse
• Advanced analytical skills, with the ability to interpret and synthesize complex data sets
• Good business acumen and political savvy
• Knowledge of business process improvement techniques and strategies
• Excellent verbal and written communications skills
• Negotiation skills
• Presentation skills
• Decision-making skills
• Good problem-solving skills
• Ability to interface with employees at all levels
• Ability to effectively navigate ambiguous situations with limited direction
• Excellent organizational skills and ability to successfully prioritize multiple tasks
• Ability to handle multiple priorities/projects

The extras:

• Certified Professional Coder (CPC) designation
• Experience with anti Fraud, Waste, Abuse investigations

Location:

BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal.

We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week.

Permitted to reside in the following states, pending approval from the Human Resources Department:

• Arizona
• Connecticut
• Florida
• Georgia
• Louisiana
• Massachusetts
• North Carolina
• Oklahoma
• Rhode Island
• South Carolina
• Texas
• Virginia

Additional information:

BCBSRI is an equal opportunity employer. The law requires an employer to post notices describing the Federal laws. Please visit www.eeoc.gov/know-your-rights-workplace-discrimination-illegal to view the "Know Your Rights" poster.