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Fraud Investigator Associate

Little Rock, AR | Full Time
5 Days Ago

Job Description

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here. Workforce Scheduling Flex Job Summary The Fraud Investigator conducts healthcare fraud, waste and abuse investigations involving medical professionals, insured members and employees; and resolves allegations or suspicions of fraud. Incumbent proactively identifies trends and aberrant activity to generate leads for fraud investigations and analyzes data to detect fraudulent activity. May be required to testify in criminal and civil matters. Requirements Education Bachelor’s degree, preferably in Criminal Justice or related field. In lieu of degree, five (5) years of health related non-clerical healthcare operations experience, such as claims, membership, and/or customer service will be considered. Alternatively, four (4) years of law enforcement experience will be considered. Experience 1. Proficiency working with MS Office Suite, such as Word and Excel. 2. Possess in-depth knowledge of health insurance operations such as claims processing, membership, enrollment, customer service, financial and provider systems preferred. 3. Previous health insurance investigation experience desirable. Specialized Knowledge & Skills • Critical thinking & decision making • Problem sensitivity • Excellent communication skills • Attention to details • Excellent written and grammar skills • Excellent analytical skills • Strong interpersonal skills • Understanding of claims processing systems and medical claims coding. Professional Certification or Licenses: Health Care Anti-Fraud Associate (HCAFA) preferred. Accredited Health Care Fraud Investigator (AHFI) preferred. Skills Analytical, Critical Thinking, Decision Making, Detail-Oriented, Interpersonal Relationships, Oral Communications, Working Independently, Written Communication Responsibilities Assists in collaborations with various internal departments and external agencies, such as regulators, law enforcement, attorneys and Department of Insurance and maintain a strong working relationship., Assists in criminal and civil matters as needed., Assists in process improvement recommendations of benefit, contract, and/or system edit changes for the prevention of future fraudulent activity., Documents investigative preliminary case reports, for both internal tracking and regulatory reporting purposes., Gathers information pertinent to the case and assists in developing testimonials regarding the investigation, Maintains confidentiality and possess a high level of integrity., Performs other duties as assigned., Recognizes interrelationships, significant patterns or trends, providing sound judgement and decision making to proactively generate leads for fraud investigations., Researches and investigates healthcare fraud, waste, and abuse utilizing claims data analysis and reporting, auditing providers, witness interviews, and other sources to identify abnormalities and questionable practices; documenting relevant findings and reporting any illegal activities in accordance with all laws and regulations, Stays abreast of the fraud, waste and abuse standards and practices to ensure compliance with state and federal regulations and protect the enterprise from reputational and financial risk. Certifications Accredited Health Care Fraud Investigator (AHFI) - The National Health Care Anti-Fraud Association (NHCAA), Health Care Anti-Fraud Associate (HCAFA) - American Health Insurance Plans (AHIP) Security Requirements This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual. Segregation of Duties Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual. Employment Type Regular ADA Requirements 1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting and routinely travels for work within walking distance of location of primary work assignment

Company Overview

  • Website
  • Headquarters LITTLE ROCK, AR
  • Size 1,000 - 3,000
  • Founded 1948
  • Type
  • Revenue $1B - $3B
  • Industry Insurance
  • About usable mutual insurance company
  • For 70 years, Arkansas Blue Cross and Blue Shield has been a trusted partner to Arkansans by providing reliable insurance plans while also being a valuable community partner. We live here, work here and raise our families here - we are dedicated to Arkansas and to you. We work hard to improve the health, financial security and peace of mind to the members and communities we serve. Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association.

Skills for Fraud Investigator Associate

The job skills required for Fraud Investigator Associate include Futures, Written Communication, Customer Service, Attention to Detail, Data Analysis,and Communication Skills etc. Having related job skills and expertise will give you an advantage when applying to be a Fraud Investigator Associate. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Fraud Investigator Associate. Select any job title you are interested in and start to search job requirements.

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Career Path for Fraud Investigator Associate

The following is the career advancement route for Fraud Investigator Associate positions, which can be used as a reference in future career path planning. As a Fraud Investigator Associate, it can be promoted into senior positions as a Fraud Detection Associate III that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary Fraud Investigator Associate. You can explore the career advancement for a Fraud Investigator Associate below and select your interested title to get hiring information.