Program Integrity Analyst/Investigator Clinical - Behavioral Health

BCBSM, Inc.; Eagan (MN); Hybrid; USD 69,000 - 114,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

Life insurance

401k

Paid Time Off (PTO)

Volunteer Paid Time Off (VPTO)

Job summary

Blue Cross and Blue Shield of Minnesota is seeking a healthcare investigations professional to analyze referrals, conduct investigations into fraud, waste, and abuse, and prepare case referrals. You will interview patients, providers, and witnesses, and review medical records for accuracy and compliance.

The role is hybrid, with two days onsite, and offers a comprehensive benefits package, including medical, dental, life, 401k, PTO, VPTO, and more.

Qualifications

• 3+ years of healthcare operations auditing/investigations experience.
• Ability to travel during the workday and overnight travel.

Responsibilities

• Analyze and triage referrals to determine research/investigation needs.
• Investigate moderate to complex potential fraud, waste or abuse; document findings and referrals.
• Interview patients, providers, and witnesses; review medical records for appropriateness.

Skills

Healthcare experience

Investigation skills

Data analysis

Travel willingness

Education

Bachelor’s degree

Job description

About Blue Cross and Blue Shield of Minnesota

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

The Impact You'll Have

In this position, you will be responsible for the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse and over-payment recovery cases. This includes gathering, analyzing and interpreting complex data and information to provide meaningful results in developing leads, collaboration with internal resources as well as complying with state and federal requirements for fraud, waste and abuse detection and prevention.

What You'll Do

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.

How You'll Do It

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. Performs additional responsibilities consistent with the scope and level of the role, as assigned.

Required Skills & Experience

3+ years of related healthcare, operations auditing/investigations, professional experience. Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted. Ability to travel during the workday and potential overnight travel.

Preferred Skills & Experience

Ability to tailor communication to varied audiences, actively listen to uncover requirements, and ensure accurate and timely information exchange. Ability to analyze information, identify patterns and root causes, and collaborate with partners to implement practical solutions. Ability to effectively organize work, balance competing priorities, and manage time across multiple responsibilities and deadlines. Healthcare or health insurance industry experience. Previous non-financial audit experience. Knowledge of industry audit standards and statistical sampling. 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. Knowledge of and ability to comply with applicable federal, state, and local employment laws, regulations, and compliance requirements. Ability to maintain discretion and confidentiality.

Licensure/Certifications 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.

Role Designation

Hybrid Role designation definition: Teleworking is working full time remote. Hybrid is a minimum of 2 days onsite. Onsite is full-time onsite.

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week – most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you are empowered to work remote.

Compensation and Benefits

$68,900.00 - $91,300.00 - $113,700.00 Annual Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job. We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

Equal Employment Opportunity Statement

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affi ... All qualified applications will receive consideration for employment without regard to, and will not be discriminated against based on any legally protected characteristic. Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: [e-mail]. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

Headquartered in Eagan, Minnesota.