About Blue Cross and Blue Shield of Minnesota

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

The Impact You Will Have

In this position, you will be responsible for prospective and retrospective investigations of suspected 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.

Your 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.
• 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.

Required Skills and Experience

• 3+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• 4 years of fraud, waste and abuse investigation/ loss prevention experience and experience using data analysis tools (e.g. GDIT STARS Informant, STARS Sentinel, etc.).
• Excellent demonstrated written and oral communication, interpersonal and negotiation skills to communicate with management, regulators and law enforcement.
• Proven 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.
• Strong organizational skills and the ability to manage and prioritize multiple investigations, projects and responsibilities.
• Ability to work independently with excellent attention to detail.
• Proficient use of Microsoft Word, Excel, PowerPoint and Visio.
• Accredited Health Insurance Fraud Investigator (AHFI) in good standing through the National Health Care Anti- Fraud Association (NHCAA) within three years of hire.
• This role requires the ability to travel during the workday and potential overnight travel.
• Required to have and maintain a valid driver's license and auto insurance or access to reliable transportation.
• High school diploma (or equivalency) and legal authorization to work in the U.S.

Preferred Skills and Experience

• Bachelor's Degree

Compensation and Benefits:

Pay Range: $67,200.00 - $89,100.00 - $111,000.00 Annual

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

To discover more about what we have to offer, please review our benefits page.

Role Designation

Hybrid

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week – most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you are empowered to work remote.

Equal Employment Opportunity Statement

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan, as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to, and will not be discriminated against based on any legally protected characteristic.

Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talent.acquisition@bluecrossmn.com.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.