PRINCIPAL ACCOUNTABILITIES: Under the direction of the SI Post-Pay Supervisor, functions include but are not limited to: Perform data analytics to identify fraud, waste or abuse in claims data. Proactively identify instances of potential fraud, waste and abuse through data analysis using company systems and tools. Utilize knowledge of healthcare coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies and relevant laws to find suspicious patterns in claims data and other sources. Develop and maintain general knowledge healthcare reimbursement policies and state and federal regulations related to healthcare fraud and abuse. Provide comparative analysis of data and apply it to external audit methodology and operational/business needs. Collaborates with departmental staff, management and other internal departments to collect and analyze corporate records as directed by management. Assist Investigators and staff in preparing FEP cases for referral to OPM-OIG for potential criminal or civil litigation when appropriate. Work with BCBSA Consultant in supporting that cases are referred to the OPM-OIG in accordance with Contract CS 1039 and the FEHBP Carrier Letters.
Extract complex formulated data from corporate systems and produce operational ad-hoc reports for use in conducting audit examinations of providers. Communicate results of reports in both verbal and written form to all levels of the company as well as to external entities when required and appropriate. Gathers and conducts forensic analysis of corporate records and related billing data to build profiles of individuals or groups potentially participating in fraud, waste or abuse against CareFirst. Performs complex data retrieval and analysis relating to professional, facility, pharmacy and vendor billing histories. Researches and prepares summaries of medical and payment polices for use by Investigators. Compiles findings, recommendations and conclusions into financial investigative reports. On occasion will accompanying Investigators on interviews of subjects and key witnesses. Performs other duties as necessary or appropriate to position. QUALIFICATIONS: Required: Bachelor's degree in Business, Healthcare Analytics, Mathematics, Statistics or related field, with at least 4 years of experience in healthcare data analysis and report design or the equivalent combination of education and experience. Abilities/Skills:
Demonstrated experience with Microsoft Office products and strong Excel skills
Excellent oral/written communication and interpersonal skills
Provides consulting and analytic services to leadership
Perform analytic tasks for internal or customer specific projects
Experience with report writing and business correspondence
Ability to coordinate activities with varying levels of management, staff, external agencies, and medical professionals through strong verbal and written communications
Evaluate and preprocess raw information
Ability to plan, organize, and manage projects with minimal supervision
Ability to deliver results within agreed upon timeframes
Highly motivated, with strong drive, team spirit, and organizational skills
Ability to work effectively both independently and as a team-member
Proven judgment, analytical, decision making, and problem-solving ability
Dependable with the highest level of integrity
Demonstrate ability to comprehend Federal/State law and desire to further knowledge with additional education
Ability to handle highly confidential and sensitive information while ensuring compliance with the Company's privacy policies
Ability to travel as required, including occasional overnight stays. Must have transportation.
Preferred: Certified Health Data Analyst (CHDA®), Credentials as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), or Certified Professional Coder (CPC). In depth knowledge of corporate and divisional policies and procedures, claims processing, underwriting, medical policies, enrollment and billing and/or other related systems and procedures to determine the integrity of claims’ payments and business operations within CareFirst or previous experience in the healthcare industry.
Department: Post Payment Unit - MD
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Actual salary will be based on relevant job experience and work history.
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. Travel may be required between CareFirst sites and to other business-required destinations. The physical demands described here are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
Must be eligible to work in the U.S. without Sponsorship