Senior Fraud Investigations Analyst

Blue Cross and Blue Shield of North Carolina • Wyoming, MI

2d • $81,068 - $129,708 • Hybrid

About The Position

We are seeking a Special Investigations Unit (SIU) Investigator to conduct timely and thorough health care fraud investigations on behalf of our Company. Responsibilities include maintaining confidentiality, adhering to SIU Policies and Procedures, meeting contractual obligations, and ensuring compliance with state and federal regulations.

Requirements

• Bachelor's degree or advanced degree (where required)
• 5+ years of experience in related field. In lieu of degree, 7+ years of experience in related field.
• Strong Excel skills for organizing, tracking, and reviewing case data (e.g., filtering, sorting, basic formulas, pivot tables)
• Strong written and verbal communication skills, particularly in provider-facing interactions
• Ability to manage multiple cases and deadlines in a fast-paced investigative environment

Nice To Haves

• Working knowledge of Medicare programs and reimbursement principles, including general billing requirements and documentation expectations
• Professional certifications such as AHFI (Accredited Healthcare Fraud Investigator), CFE (Certified Fraud Examiner), or similar healthcare fraud or compliance credentials
• Experience reviewing and vetting investigative leads and determining appropriate next steps
• Experience communicating investigative findings, summaries, and overpayment determinations clearly to internal stakeholders and/or providers
• Familiarity with common fraud, waste, and abuse (FWA) schemes and red flags

Responsibilities

• Conducts investigations in accordance with investigative action plan and documents all findings in standard with SIU Policies and Procedures
• Identifies errors and control deficiencies.
• Understands and communicates the downstream impact of process weaknesses and gaps on the business/organization.
• In the course of investigation, may be required to provide deposition and/or testimony
• May also be required to conduct interviews of victims, subjects and/or other related persons
• In accordance with SIU Policies and Procedures, maintains timely and factual documentation in designated case tracking, from inception to case closure
• Prepares and conducts presentations and/or provides content for health care fraud and abuse education and awareness.

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs.
• Parental leave and support plus adoption and surrogacy assistance.
• Career development programs and tuition reimbursement for continued education.
• 401k match including an annual company contribution

What This Job Offers

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