Police & Fire
Mountlake Terrace, Washington
Premera Blue Cross
7001 220th Street S.W.
Application Deadline: NA
innovation and strategy to create leading-edge health coverage and benefit
solutions for our members.
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:
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.
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
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
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
Participate on special projects,
committees, and task forces as assigned.
Some overnight travel required.
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
Ability to operate a PC and standard
Microsoft Windows XP software package - MS Word, MS Excel, Outlook and web
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.
AHFI or CFE strongly preferred. CPA
or RN a plus.
Bilingual skills would be a plus.
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