Fraud Investigator

Responsible for conducting thorough and accurate investigations of all cases assigned, throughout the State of Michigan and nationally for Blue Cross Blue Shield of Michigan (BCBSM). Conduct investigations to establish facts necessary to support leadership decision to refer to law enforcement. If investigation does not substantiate criminal prosecution investigator will initiate administrative steps and/or to pursue civil or recovery action.

• Perform investigative strategiesutilizing industrywide best practices.
• Prepare detailed reports of all investigative findings and present to BCBSM leadership for review.
• Pursue independent review by lawenforcement for potential criminal prosecution when probable cause has been determined.
• Present detailed and accurate testimony to federal, state and local courts as well as other state hearings and hearings required by the Master Labor Agreement.
• Report improper or inadequate policies and procedures of all BCBSM systems detected during investigations to leadership for collaborationwith the audit areas of the company.
• Serve as a liaison between BCBSM customers,and federal, state and local law enforcement agencies in order to attain investigative objectives.
• Prioritize cases to properly manage caseloads to maximize the cost effectiveness of investigative time.
• Utilize administrative controls and loss prevention techniquesto mitigate Fraud, Waste and Abuse (FWA) as early as possible.
• Ensure compliance in reporting FWA allegations within Health Plan Business including Emerging Markets and all government sponsored programs.
• Collaborate with other Blues Plans, Blues Association and national partnersto identify FWA trends and schemes to protect the enterprise.
• May be responsible for investigations into violations of code of conduct and compliance policy.

QUALIFICATIONS

• Bachelor's Degree in Criminal Justice, Business Administration or related field is preferred.
• Five (5) years of experience investigating financial fraud, internal affairs, healthcare fraud, insurance fraud or complex investigations required. Experiencewithina federal, state, or local law enforcement agency is preferred.
• AccreditedHealthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC) certification(s) is preferred.
• Intermediate analytical, decision making, organizational, problem solving, critical thinking, verbal, and written communication skills.
• Ability to work with moderate direction and independently in sensitive situations.
• Intermediate proficiency using applications and systems (i.e. Excel, Word, etc.).
• Knowledge of investigative techniquesi.e. witness and suspect interviews, evidence gathering, surveillance, undercover activity and investigative report writing.
• Possess an understanding of federal, state, and local judicial processes and statutes relating to fraud prosecutions.
• Knowledge of financial investigative techniques and the investigation of health care fraud.