Program Integrity Analyst/Investigator Clinical - Behavioral Health

Blue Cross Blue Shield of Minnesota•Eagan, MN

8d•Hybrid

About The Position

In this position, you will be responsible for the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse and over-payment recovery cases. This includes gathering, analyzing and interpreting complex data and information to provide meaningful results in developing leads, collaboration with internal resources as well as complying with state and federal requirements for fraud, waste and abuse detection and prevention.

Requirements

3+ years of related healthcare, operations auditing/investigations, professional experience.
Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted.
Ability to travel during the workday and potential overnight travel.
Registered nurse or licensed behavioral health clinician (i.e. LICSW, LPCC, LMFT, LP, LADC, LBS, BCBA) with current MN license and no restrictions or pending restrictions.

Nice To Haves

Ability to tailor communication to varied audiences, actively listen to uncover requirements, and ensure accurate and timely information exchange.
Ability to analyze information, identify patterns and root causes, and collaborate with partners to implement practical solutions.
Ability to effectively organize work, balance competing priorities, and manage time across multiple responsibilities and deadlines.
Healthcare or health insurance industry experience.
Previous non-financial audit experience.
Knowledge of industry audit standards and statistical sampling.
Analytic, writing and reasoning skills, including the ability to evaluate complaints, referrals and health care data laws and regulations and relevant federal laws and regulations, including but not limited to HIPAA.
Knowledge of and ability to comply with applicable federal, state, and local employment laws, regulations, and compliance requirements.
Ability to maintain discretion and confidentiality.

Responsibilities

Analyze and triage referrals/leads and determine appropriate research/investigation needed with minimal guidance.
Proactively identify, analyze, investigate and evaluate moderate to complex potential fraud, waste, or abuse, including pre-pay and/or post-pay medical claims reviews to determine valid cases for appropriate action; document findings, and prepares case referrals, letters, and reports.
Conduct interviews of patients, providers, provider staff and other witness/experts.
Utilize clinical expertise, health plan knowledge, and claims analysis to review and assess medical records for appropriateness.
Represent Blue Cross by testifying at trials, offering depositions and responding to subpoenas.
Prepare for and facilitate settlement negotiations with providers, attorneys and other responsible parties with minimal supervision.
Document case activity, and fund allocation and conduct follow-up-actions in a timely manner following documented departmental guidelines.
Refer well documented and substantiated cases to law enforcement agencies which may include the Federal Bureau of Investigations (FBI), the Office of the Attorney General (OIG) and local police departments.
Meet all contractual, State and Federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS and other agencies.
Performs additional responsibilities consistent with the scope and level of the role, as assigned.