Global Healthcare Fraud Investigator

Job Description

Job Description

Who we are

At Blue Cross Blue Shield Global SolutionsSM (BCBS Global SolutionsSM), we make it easy for people and organizations to access and pay for healthcare abroad. By combining digital innovation with human-centered care, we go above and beyond for our customers and deliver an international healthcare experience that’s simple, efficient, and human. Whether our customers live, work, travel or study abroad, we give them the confidence and peace of mind to embrace every journey and say “yes” to new possibilities.

The Fraud Investigator is on the front line of the company's effort to reduce unnecessary medical costs and make healthcare more affordable for our customers around the globe. The investigator is responsible for the end-to-end investigation process on known or suspected acts of fraud and abuse on healthcare claims around the globe, from information gathering and interviews to financial recoveries and law enforcement collaboration.

Responsibilities:

• Evaluate and gather information related to cases of known or suspected fraud.
• Analyze historic claims to determine the full scope of identified fraudulent activity.
• Develop an investigation strategy for each case to assist in timely and successful resolution.
• Conduct interviews/interrogations with customers, providers, witnesses, authorities, and other people involved in the case.
• Document your activities in a logical, clear, and concise format, concluding with a comprehensive written investigation report.
• Facilitate the recovery of fraud and abuse related over payments of company and customer funds.
• Collaborates with law enforcement agencies as appropriate, including potentially testifying to investigation details in court.
• Researches and prepares information for management and client reporting.
• Coordinate activities across other departments (ex. Clinical, Legal, Provider Finance,Global Service Center, Claims) and external entities (ex. BlueCross Blue Shield home plans, law enforcement).
• Partner with legal and compliance to ensure all state, federal, and international requirements for investigations and fraud reporting are adhered to.
• Identify and deliver on continuous improvement opportunities.

Additional Responsibilities May Include:

• Develop process documentation for new and existing processes.
• Develop and deliver training to internal and external teams.
• Partner with IT to develop new and enhanced tools for fraud detection and investigation workflow management.
• Other duties as assigned.

Requirements:

• College degree or equivalent experience required.
• Fraud examination certification or equivalent credentials highly valued.
• Minimum 2 years of investigation experience or 4 years of insurance industry experiencerequired;5-7years preferred.
• Demonstrated experience conducting international health insurance fraud investigations strongly preferred.
• Strong attention to detail and problem-solving skills.
• Excellent written and verbal communication skills.
• Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
• Ability to manage ambiguity and drive for resolution.
• Multilingual strongly preferred.
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

What you’ll get in return:

• Competitive annual salary based on experience within a similar role
• Annual bonus
• Competitive medical plans
• Telemedicine available
• Paid parental leave
• Employee assistance and wellness support 24/7
• Free international healthcare coverage

Other Great Perks:

• Hybrid work model
• Work abroad arrangements available
• Generous PTO accrual program with carry-over option
• 9 paid holidays in addition to one floating holiday and one volunteer day
• Tuition reimbursement
• Career/Learning and development opportunities
• 401(k) with generous company match
• Pet insurance offerings
• Identity theft and legal coverages available
• Emphasis on well-being (Virtual well-being platform, monthly mindfulness events, and giveaways)