Pay Range:

$65,600.00 - $98,400.00

Please email if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

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

Blue Cross Blue Shield of Rhode Island

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