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