Fraud Investigator

Blue Cross & Blue Shield of Rhode Island•Providence, RI

6d•$65,600 - $98,400

About The Position

The Fraud Investigator responds to reports of potential provider or member fraud and abuse and investigates fraudulent or abusive activities involving members, providers, and organizational accounts. The role ensures adherence to corporate and regulatory requirements, identifies claims patterns and behaviors that may indicate fraudulent practices or billing abuse, and applies regulatory and contractual requirements and internal policies throughout investigations. The investigator analyzes enrollment information, contract terms, financial records, claims histories, and other documentation; uses data analysis, research, claims review, and SAS Fraud Framework to identify trends and emerging issues; and conducts audits and interviews. The role maintains case documentation and database records, coordinates with external agencies and law enforcement, prepares data requests, writes reports, presents findings, and tracks claim adjustments, settlements, payment plans, and restitution. The position also supports fraud-prevention training and departmental projects. BCBSRI offers in-office, hybrid, and remote schedules depending on the role. For remote work, residence is permitted in specified states pending Human Resources approval. The posted pay range is $65,600 to $98,400.

Requirements

Bachelor’s degree in Business Administration or a related field, or an equivalent combination of education and experience.
Three to five years of experience interpreting healthcare and claims payment information or conducting audit activities.
AHFI or CFE designation, or the ability to obtain one during employment.
Knowledge of fraud investigation techniques and state and federal regulations and statutes concerning fraud, waste, and abuse.
Advanced analytical skills, including the ability to interpret and synthesize complex data sets.
Good business acumen and political savvy.
Knowledge of business process improvement techniques and strategies.
Excellent verbal and written communication skills.
Negotiation, presentation, decision-making, and problem-solving skills.
Ability to interface with employees at all levels.
Ability to navigate ambiguous situations effectively with limited direction.
Excellent organizational skills and ability to prioritize multiple tasks and manage multiple priorities or projects.

Nice To Haves

Certified Professional Coder (CPC) designation.
Experience with anti-fraud, waste, and abuse investigations.

Responsibilities

Respond to reports of potential fraud and abuse and investigate activities involving members, providers, and organizational accounts.
Analyze enrollment data, contract terms, financial records, claims histories, and other documentation to determine fraud or abuse and identify patterns.
Apply regulatory and contractual requirements and internal policies and procedures to case investigations.
Perform data analysis, research, and claims review using SAS Fraud Framework to identify trends, patterns, outliers, and emerging healthcare fraud, waste, and abuse issues.
Conduct audits and interviews to support investigations.
Maintain case documentation and update the fraud database with calls, referrals, and inquiries.
Establish and maintain relationships with external agencies, including the Department of Health, Office of Inspector General, Pharmacy Benefit Manager, Federal Drug Enforcement, OPM, the Rhode Island Attorney General, the U.S. Attorney General, and state and local law enforcement.
Prepare data requests from external law enforcement agencies.
Write reports, present findings to healthcare providers, and participate in negotiated resolution of issues as directed by SIU management.
Track claim adjustments, settlement agreements, payment plans, and court-ordered restitution resulting from investigations.
Attend required training and assist with fraud-prevention training for associates and external customers.
Participate in departmental initiatives and projects.
Perform other duties as assigned.