The Impact You Will Have

In this position, you will be responsible for the daily supervision of fraud investigation activities including ensuring that key steps are being documented to meet all legal and regulatory reporting requirements. This position works under the direction of the Manager, Operational Risk Management (SIU). This position ensures SIU department objectives are being met including guiding, leading, coaching and developing associates to become increasingly self-directed; striving to create and maintain high-functioning and collaborative teams; documenting department processes; preparing and delivering presentations to other business areas and account customers; and conducting case reviews to ensure that processes are followed investigative activities are appropriately documented.

Your Responsibilities

• Oversees the ongoing FWA investigative activities of assigned associates to ensure work is being performed in accordance with accepted industry practices, contractual arrangements, Blue Cross licensure, and regulatory requirements.
• Lead complex recovery projects, audits and investigations working with cross functional teams and presenting findings to appropriate stakeholders. Independently identify, analyze and report on results, draw conclusions and present recommendations on proposed actions in a concise and effective manner. Effectively identify, investigate, and evaluate complex potential fraud, waste, or abuse, including pre-pay and/or post-pay medical claims reviews to determine valid cases for appropriate action; documents findings, and prepares case referrals, letters, and reports.
• Identify content changes for departmental processes and procedures and ensure they are updated to include regulatory and contractual guidelines and lead cross divisional collaboration efforts to ensure that SIU processes do not adversely affect the ability to meet corporate licensure, regulatory and contractual requirements.
• Represent Blue Cross by testifying at trials, offering depositions, and responding to subpoenas. Coordinate responses to requests for information and represent the SIU during regulatory and contractual audits.
• Collaborate with law enforcement agencies including the Federal Bureau of Investigations, the Office of the Attorney General, local police departments, etc. and assist the Blue Cross Legal department in pursuing cases at a national level.
• Develop education opportunities; and deliver education and training internally and for external events such as Provider Seminars, Blue Expo, Community Events, a Retail Store etc.
• Oversee and coordinate the work of other investigators to ensure thorough and complete investigations as well as the regulatory requirements are being met. Oversee the maintenance, enhancement and troubleshooting of fraud, waste and abuse detection tools. Monitor and report on team effectiveness of meeting contractual, State and Federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS and other agencies.