Premera Blue Cross Senior Investigator - Special Investigation Unit in Mountlake Terrace, Washington

Join Our Team: Do Meaningful Work and Improve People’s Lives

Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. So are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

As a Senior Investigatorfor our Special Investigations Unit, you will investigate allegations of fraudulent activities perpetrated by health care providers, facilities, subscribers, brokers and/or employer groups. The team has a diverse background with experience in law enforcement, FEP/Government and other healthcare related fields. You will assist in the development of this program and make modifications along the way as it evolves. You will initiate, analyze, develop, successfully complete and resolve audits of mid to high level complexity. In addition, you will coordinate efforts to recover erroneous payments made due to claims processing error, misrepresentative billing, fraud, abuse or any other criminal act.

Relocation Assistance is available/negotiable

What you’ll do:

  • Analyze healthcare claim data and vet referrals to detect fraudulent activity and independently determine the most effective and efficient method of investigation for each individual case

  • Perform investigative field work to include on-site office visits and record collection, and surveillance

  • Prepare cases, testify and give depositions to law enforcement and regulatory agencies for potential criminal prosecution

  • Develop and maintain collaborative and liaison relationships with BCBSA, BCBS Plans, HHS OIG, other carriers' anti-fraud professionals, law enforcement and regulatory agencies

  • Make recommendations for creating SIU policies, procedures, workflows and process improvements

What you’ll bring:

  • Bachelor’s degree in business administration, health care administration, finance, accounting, nursing or criminal justice or four (4) years’ work experience in field of study

  • Five (5) years’ experience in fraud investigation, special investigation unit, or a related field of which includes at least four (4) years of active experience in auditing and investigating in the healthcare industry

  • Experience with Medicare is a definite plus

  • Medical, medical insurance, investigations or coding background with the ability to obtain a CPC within one year of employment

  • RN, CPC, CFE, or AHFI would be a plus

  • Strong understanding of health insurance reimbursement methodologies, including familiarity with ICD-10 CM, CPT and HCPCS coding

  • Demonstrated strong technical writing skills to generate reports and business correspondence and to prepare case files

  • Proven ability to present and communicate complex subjects to all levels of associates, management and external contacts

  • Experience with relevant technology, such as background check systems, claims processing platforms, data mining and fraud detection software

  • Ability to maintain in-depth working knowledge of fraud identification and investigation techniques and provide technical support and guidance to less experienced team members

  • Knowledge of regulations or laws pertaining to insurance fraud and judicial processes relating to fraud prosecutions

Must be willing and able to attend conferences (BCBSA, NHCAA, and ACFE) and webinars to keep apprised of developments in health care fraud

What we offer:

  • Industry competitive salaries

  • Medical, vision and dental options

  • Life and disability insurance

  • Retirement programs (Yes! This includes a pension!)

  • Workplace wellness programs

  • Time off to reenergize

  • Free parking

  • And MORE!

Job Title: Senior Investigator - Special Investigation Unit

Job ID: 11431

Location: Mountlake Terrace, WA

Full/Part Time: Full-Time

Regular/Temporary: Regular

Equal employment opportunity/Affirmative action

Premera is an equal opportunity / affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, national origin, gender or gender identity, sexual orientation, age, genetic information, disability or veteran status. All staff of Premera and its subsidiary companies must demonstrate the legal right to work in the United States. Premera is an E-Verify employer.