Premera Blue Cross

Premera’s culture promotes individual development, fosters innovation, and rewards success. We are creative, strategic thinkers who use our talents to fulfill our mission of creating peace of mind for our members. First established in 1933, the Premera family of health-care companies is headquartered in Washington and serves over 1.5 million members in several Western States. Our unique value proposition is built on a strong local presence and national capabilities.

If you would like to apply your skills and experience to create health-care solutions, consider the following position:

Job Summary:

As a member of Premera's Special Investigations Unit, this individual will be responsible to investigate allegations of fraudulent activities perpetrated by health care providers, facilities, subscribers, brokers and/or employer groups. This Investigator will initiate, analyze, develop and successfully complete and resolve fraud investigations of mid- to high-level complexity. Investigations must be conducted in accordance with company policies and procedures and in compliance with all applicable laws and regulations.

Responsibilities:

Detect fraudulent activity and independently decide the most effective and efficient method of investigation for each individual case.
Manage a full caseload - perform multiple high quality investigations concurrently by prioritizing work and delegating activities to Coordinator, Analyst and other SIU team members.
Gather and analyze data and information from internal and external sources - including claims history databases, public record information systems, other insurance carriers and law enforcement officers.
Collect and preserve detailed evidence for the successful prosecution of cases.
Perform investigative field work, such as on-site medical record audits, surveillance and undercover operations.
Interview suspects and witnesses.
Prepare cases for referral to law enforcement and regulatory agencies for potential criminal prosecution.
Testify and give depositions on behalf of Premera as an expert witness in legal proceedings.
Represent Premera in conducting settlement negotiations with attorneys and other responsible parties.
Document all stages of each investigation using Company and department procedures, templates and forms.
Prepare post-investigative reports directed towards the prevention of fraud through the identification of root-cause problems and issues in the Company's claims payment systems, contracts, policies and procedures.
Maintain in-depth working knowledge of fraud identification and investigation techniques.
Keep SIU staff apprised of current or newly discovered fraud issues, trends and schemes.
Develop and maintain collaborative relationships with BCBSA, BCBS Plans and other carriers' anti-fraud professionals.
Develop and maintain liaison relationships with Federal, State, and local law enforcement agencies.
Participate in regular and ad hoc meetings and task forces with law enforcement agencies and other insurance carriers' investigative staff.
Attend conferences (BCBSA, NHCAA, ACFE) to keep apprised of developments in health care fraud.
Handle highly confidential and sensitive information while ensuring compliance with the Company's privacy policies.
Participate on special projects, committees, and task forces as assigned.
Some overnight travel required.

Minimum Qualifications:

BS/BA from a 4-year college or university - preferably in business administration, health care administration, finance, accounting, nursing or criminal justice. Experience in lieu of education would be considered.
Minimum 3 to 5 years successful experience in law enforcement, fraud investigation, special investigative unit, forensic computer analysis or a related field of which 5 years involved investigative responsibilities. At least 3 years of active experience in health insurance fraud, specifically.
Proficiency in establishing, documenting and independently pursuing appropriate investigative strategies. Case referral and related prosecution experience required.
Comprehensive knowledge of regulations and laws pertaining to insurance fraud and judicial processes relating to fraud prosecutions.
Excellent communication, negotiation and interrogation skills. Must be capable of taking the lead in interviews with witnesses, suspects and/or their attorneys.
Demonstrated strong technical writing skills, ability to write reports and business correspondence prepare case files.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures and government regulations.
Proven ability to present and communicate complex subjects to all levels of associates, management and external contacts.
Ability to operate a PC and standard Microsoft Windows XP software package - MS Word, MS Excel, Outlook and web browsers.
Experience with relevant technology, such as background check systems, claims processing platforms, data mining and fraud detection software.
Strong understanding of health insurance reimbursement methodologies, including familiarity with ICD-9 CM, CPT and HCPCS coding.
Ability to travel as required.
Must have a valid driver's license and a good driving record as well as use of an automobile that is properly licensed and insured pursuant to all legal requirements.

Additional Qualifications Preferred:

AHFI or CFE strongly preferred. CPA or RN a plus.
Bilingual skills would be a plus.

To apply please go to:

www.premera.com/employment

Do you need to finish your degree?

Click Here for a list of all our college programs

Return to the Featured Department List

750 7/21/06-10/8/06