Investigator III

Premera; Mountlake Terrace (WA); Hybrid; USD 80,000 - 118,000; Full time

Benefits offered by this job

Medical coverage

401K match

Pension plan

Tuition assistance

On-site parking

Job summary

Premera, a not-for-profit health plan based in Mountlake Terrace, WA, is hiring an Investigator III for its Special Investigations Unit. Hybrid role, located in Mountlake Terrace with options for Anchorage or Spokane.

The investigator leads complex fraud cases, analyzes data, conducts interviews, delivers thorough case reports, and works with law enforcement. Requires a bachelor’s degree or 4 years’ related experience and SIU expertise.

Qualifications

• Bachelor’s degree in business administration, health care administration, finance, accounting, nursing or criminal justice or 4 years of work experience.
• Three 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) preferred.
• Two years of active experience in auditing and investigating in the healthcare industry.

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.
• Attend webinars and conferences like BCBSA, NHCAA, and ACFE to keep apprised of developments in health care fraud.

Skills

Fraud investigation

Data analysis

Regulatory knowledge

Report writing

Interviews / interviewing

Education

Bachelor’s degree in business administration, health care administration, finance, accounting, nursing or criminal justice

Tools

Excel

Access

Focus

Job description

Workforce Classification: Hybrid Join Our Team: Do Meaningful Work and Improve People’s Lives Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare. Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for.

Learn more about our recent awards and recognitions as a greatest workplace. Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/. As a member of Premera’s Special Investigations Unit (SIU), the Investigator III leads complex investigations into allegations of external fraud, waste, and abuse (FWA).

This role manages medium to ‑high complexity cases from initiation through resolution, producing thorough, ‑well documented investigative reports that may be subject to legal discovery. The Investigator III conducts detailed analysis, collaborates closely with SIU colleagues, and balances multiple investigations simultaneously. In this role, you will also work to identify and recover improper payments resulting from fraudulent or misrepresentative billing, while ensuring all investigative activities comply with‑ company policies, regulatory requirements, and applicable laws.

As a not-for-profit‑ organization, Premera offers the opportunity to do this work with a genuine focus on doing what’s right for our members—supported by leaders who believe in the impact this team makes, not just the metrics. This hybrid role can be based in Anchorage, Mountlake Terrace, or Spokane.

What you’ll do:

• 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.
• 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.

What you’ll bring:

• 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. (Required)
• (3) years of experience in fraud investigation, special investigation unit, or a related field. (Required)
• Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI). (Preferred)
• (2) years of active experience in auditing and investigating in the healthcare industry. (Preferred)
• 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.

Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• 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.
• For our hybrid employees, our on‑campus model provides flexibility to create your own routine with access to on‑site resources, networking opportunities, and team engagement.
• 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.

Equal employment opportunity/affirmative action:

Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at [e-mail] or via phone at 425-918-4785.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary range for this role is posted below; we generally target up to and around the midpoint of the range. National Plus Salary Range: $80,200.00 - $118,300.00 *National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska. We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all.

At Premera, we make healthcare work better. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives. As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services. Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.