Senior Fraud Investigations Analyst

Job Description

We are seeking a Special Investigations Unit (SIU) Investigator to conduct timely and thorough health care fraud investigations on behalf of our Company. Responsibilities include maintaining confidentiality, adhering to SIU Policies and Procedures, meeting contractual obligations, and ensuring compliance with state and federal regulations. What You’ll Do Conducts investigations in accordance with investigative action plan and documents all findings in standard with SIU Policies and Procedures Identifies errors and control deficiencies. Understands and communicates the downstream impact of process weaknesses and gaps on the business/organization. In the course of investigation, may be required to provide deposition and/or testimony May also be required to conduct interviews of victims, subjects and/or other related persons In accordance with SIU Policies and Procedures, maintains timely and factual documentation in designated case tracking, from inception to case closure Prepares and conducts presentations and/or provides content for health care fraud and abuse education and awareness. What You Bring Bachelor's degree or advanced degree (where required) 5+ years of experience in related field. In lieu of degree, 7+ years of experience in related field. Bonus Points Working knowledge of Medicare programs and reimbursement principles, including general billing requirements and documentation expectations Professional certifications such as AHFI (Accredited Healthcare Fraud Investigator), CFE (Certified Fraud Examiner), or similar healthcare fraud or compliance credentials Experience reviewing and vetting investigative leads and determining appropriate next steps Experience communicating investigative findings, summaries, and overpayment determinations clearly to internal stakeholders and/or providers Familiarity with common fraud, waste, and abuse (FWA) schemes and red flags Strong Excel skills for organizing, tracking, and reviewing case data (e.g., filtering, sorting, basic formulas, pivot tables) Strong written and verbal communication skills, particularly in provider-facing interactions Ability to manage multiple cases and deadlines in a fast-paced investigative environment What You’ll Get The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community. Work-life balance, flexibility, and the autonomy to do great work. Medical, dental, and vision coverage along with numerous health and wellness programs. Parental leave and support plus adoption and surrogacy assistance. Career development programs and tuition reimbursement for continued education. 401k match including an annual company contribution Learn more Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. *Based on annual corporate goal achievement and individual performance. $81,068.00 - $129,708.00 Skills Depositions, Evidence Collection, Forensic Accounting, Fraud Investigations, Investigation Techniques, Investigative Analysis, Job Interviews, Regulatory Analysis, Risk Assessments, Testifying in Court_____________________________________________________________________ JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: [email protected]. Apply To This Job