Fraud Waste and Abuse Investigator

Found in: Lensa US P 2 C2 - 2 weeks ago

Williston, United States Blue Cross Blue Shield North Dakota Full time
All about us

You likely know us as an insurance company, but that’s just a portion of what we do. Hundreds of thousands of North Dakotans trust us to provide them with personalized service and unmatched access to care. It’s a mission we take seriously.

We also work with entities throughout the state to challenge the cost and complexity of health care in North Dakota. This uncompromising goal requires caring, innovative people who are ready and willing to help create a new level of health and well-being in North Dakota and beyond.

Work environment

This opportunity is eligible for remote work or a hybrid work arrangement. We empower our employees to find a work style that is best for them. Learn more at Life at Blue | BCBSND.

This position is eligible for internal and external applications.

Pay Information

  • Opportunities for continued salary growth through performance-based incentive programs.
  • Pay Level: 021
  • FLSA: Non-Exempt Hourly
A day in the life

The Investigator is responsible for investigating moderately complex allegations of fraud, waste and abuse perpetrated by healthcare providers, facilities, members and/or groups and provides support in investigations of higher complexity. This position identifies areas of concerns using software, tips, interviews, and other means.

Your responsibilities will include
  • Uses software analysis and other resources to conduct moderately complex investigations.
  • Gathers and analyzes data from relevant resources, documenting all steps of investigations.
  • Assesses the company’s potential exposure level to help determine case prioritization.
  • Identifies aberrant patterns and/or suspected fraud, waste, or abuse practices.
  • Maintains accurate records, documentation, and evidence for each case.
  • Develops detailed formal case reports and corrective action plans as appropriate for each investigation.
  • Manages a full case load by performing multiple low to mid-level investigations concurrently.
  • Resolves cases by submitting claims for adjustment in accordance with established processes and policies.
  • Collaborates occasionally with management and/or internal staff to determine case adjudication when guidance is needed.
  • Assists in identifying internal process improvement to prevent future fraud, waste, or abuse occurrences.
  • Builds and maintains up-to-date knowledge of trends and techniques in detecting fraud, waste, and abuse.
  • Performs work under general supervision. Handles moderately complex issues and problems and refers more complex issues to higher-level staff.
What you need to succeed
  • Bachelors degree in Healthcare, Business, Finance, Criminal Justice or related field.
  • Minimum 3 years of experience in Audits, data analysis, healthcare or healthcare claims, investigations, law or related experience is required.
  • Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC) or equivalent is required or can be obtained within 6 months of hire.
  • Pays close attention to the details of all work and strives for a high level of accuracy.
  • Collaborates with other parties to accomplish goals.
  • Maintains a positive, supportive and appreciative attitude.
  • Organize and develop data to respond to audits and requests for data.
  • Ability to analyze problems and communicate proposed solutions.
  • Contributes to maintaining the integrity of the organization.
Equivalent combination of education, experience or training determined to be acceptable by Human Resources may be substituted, unless regulated by contract or program standards

Benefits and perks
  • Wellness incentives including well-being lifestyle spending accounts, employee assistance program and employee discounts.
  • Encouraged paid time off including paid holidays and flexible holidays to use as you wish.
  • 16 hours of paid volunteer time with a $200 donation to a charity of your choice upon completion of all volunteer hours.
  • Employee recognition, community initiative events and yearly company outings.
  • Workplace flexibility offering different options for working arrangements and the freedom to make time for important commitments.
  • Our core benefits include health, dental, vision and life insurance, short-term and long-term disability and paid parental leave.


Equal opportunity employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email careers@bcbsnd.com.

This job posting will be closed 4/18/2024 at 8:00 a.m. (CT). No further applications will be considered.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

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