The hiring range for this role is:
85,126.50 - 126,003.57
This is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range andthis hiringrange may also be modified in the future. A candidate’s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonusincentivepay.
We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
Job Description Summary:
Manages and conducts investigations related to fraud, theft, and other criminal activities within an organization. Develops and implements fraud prevention programs and strategies to mitigate risks and protect assets. Collaborates with law enforcement agencies, legal teams, and internal stakeholders to gather evidence, interview witnesses, and build cases for prosecution. Provides expert guidance and advice on fraud detection techniques, compliance regulations, and best practices in fraud prevention. Analyzes data, trends, and patterns to identify potential fraudulent activities and develop proactive measures to prevent future incidents. Conducts training sessions and workshops to educate employees on fraud awareness and prevention strategies.
Responsibilities include but are not limited to:
Education and Training: Develop communication materials and provide training for assigned contract requirements, compliance systems, and program standards. 20%
Documentation and Reporting: Prepare necessary reports and forms, maintain documentation to support contract and Carrier Letter requirements, and ensure timely and accurate records of case developments. 20%
Investigative Coordination: Coordinate investigative efforts among BCBS Plan Special Investigation Units (SIUs), assigned contract Pharmacy Benefit Managers (PBMs), law enforcement agencies, and other stakeholders. Provide summaries for BCBSA Legal Department and Office of Personnel Management-Office of the Inspector General, support health care fraud investigations, and deliver case presentations to U.S. Attorney Offices, as required. 20%
Subject Matter Expertise and Research: Support SIU staff as a subject matter expert (SME) on all required tracking systems. Conduct research and assist in developing anti-fraud training for assigned Plan and applicable PBM SIU staff. 15%
Relationship Building and Special Projects: Develop and maintain productive working relationships with various local, state, and federal law enforcement agencies and industry partners. Assist with special projects, including training new staff and revising applicable Standards Manuals. 15%
Programmatic Guidance and Corrective Actions: Provide programmatic Fraud, Waste & Abuse (FWA) guidance and input to PBMs, Plan SIUs, and internal BCBSA business units. Recommend and implement corrective actions to mitigate identified risks and recommend updates to processes, benefits, and protocols. 10%
Required Education, Certifications and Experience:
Education:
Experience:
4+ Years experience in law enforcement, Healthcare Fraud Investigations, nursing, healthcare plan operations, or related fields Required
Knowledge Skills and Abilities:
Excellent written and verbal communication skills.
Excellent organizational and time management skills.
Strong training and presentation skills.
Ability to research and analyze data/information and apply it appropriately and accurately.
Strong interpersonal skills and relationship development abilities.
Demonstrated technical proficiency in the use of various computer software programs, including Microsoft Office applications and databases.
Ability to exercise independent judgment to facilitate responses to inquiries/questions.
Knowledge of the Federal Employee Health Benefit Program (FEHBP).
Certifications & Licenses:
Additional information:
Five or more years of experience in law enforcement, Healthcare Fraud Investigations, nursing, healthcare plan operations, or related fields.
Experience in analyzing and responding to complex sets of information and/or processing information requests.
Prior federal, state, or local law enforcement experience.
Prior health care fraud investigative experience and/or clinical experience.
Nursing or medical coding experience.
Criminal justice experience
Prior BCBS Plan experience
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