Analyst - Clinical Review

Blue Cross Blue Shield of Michigan • Detroit, MI

1d

About The Position

Responsible for the collection, evaluation and preparation of internal data and/or documents in support of investigation related to suspected fraud, waste, abuse, and error (FWA) within claims. Resolve non-prosecutable analyst cases and prepare and maintain department investigative files and case information systems. Assist in planning and special project activities as required by the Director, Manager and Senior Analyst.
DEPARTMENTAL PREFERENCES
Seeking candidates with previous experience in clinical settings. This position focuses on clinical review of patient medical records and provider billing. Candidates must be able to interpret patient claims data for inconsistencies, completeness and quality.

Requirements

• Bachelor's Degree in a related field is preferred.
• Two (2) years of experience in a related field is required.
• Effective verbal, written communication and interpersonal skills.
• Ability to work independently or in a team environment and interact with all levels of the organization.
• Effective analytical and problem-solving skills to identify, evaluate, recommend and implement changes to processes or procedures to address problems and improve departmental effectiveness.
• Organizational skills and ability to prioritize; must be able to coordinate multiple activities with varying timelines.
• Proficient in Microsoft Office suites.
• Ability to develop and maintain effective working relationships.

Responsibilities

• Identify instances of fraud, waste, abuse, or error in Blue Cross Blue Shield of Michigan (BCBSM) claims using Healthcare Fraud Shield, the Informatics Environment, and BCBSM claims portals. Prepare case referrals for Fraud Investigators.
• Review medical records for appropriate procedure and billing in order to support FWA investigations.
• Provide Healthcare Fraud Shield and Informatics Environment training to Fraud Investigators and Fraud Analysts and technical knowledge of BCBSM products, policies and procedures.
• Utilize and maintain available reporting systems. Participate in systems testing, develop procedures/controls and provide recommendations for the ongoing improvement of the updated process
• Provide leadership team with status updates on projects and issues.
• Communicate and recommend policy changes to achieve project objectives. Assist in documenting departmental procedures.
• Create and present reports and presentations to display operational data and propose business changes.
• Provide support to both internal departments and external entities by answering questions, supplying information and training.
• Participate in special projects or workgroups as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level