Program Integrity Analyst/Investigator Clinical - Registered Nurse

About the position 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 Will Have This position is 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.

Responsibilities

• 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.
• 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.

Requirements

• 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.
• 3+ years of related professional clinical experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• 4 years of fraud, waste and abuse investigation/ loss prevention experience and experience using data analysis tools (e.g. Healthcare Fraud Shield, etc.).
• Excellent demonstrated written and oral communication, interpersonal and negotiation skills to communicate with management, regulators and law enforcement.
• Proven 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.
• Strong organizational skills and the ability to manage and prioritize multiple investigations, projects and responsibilities.
• Ability to work independently with excellent attention to detail.
• Proficient use of Microsoft Word, Excel, PowerPoint and Visio.
• Accredited Health Insurance Fraud Investigator (AHFI) in good standing through the National Health Care Anti- Fraud Association (NHCAA) within five years of hire.
• This role requires the ability to travel during the workday and potential overnight travel. Required to have and maintain a valid driver's license and auto insurance or access to reliable transportation.
• High school diploma (or equivalency) and legal authorization to work in the U.S.

Nice-to-haves

• Bachelor's Degree

Benefits

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

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