BCBS
Fraud Investigator-Kansas City, MO area
1400 Baltimore, Kansas City, MO 64105
Sponsorship not specifiedDetected 21 hours ago
Data AnalysisData VisualizationAccountingExcelCustomer SupportICD-10Pharmacy PracticeResearchCommunicationClaims Management
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odds of building a lasting career here
16Unrated
Cap-exempt (no lottery)0
Sponsors this role0
Entry-level history0
PERM / green-card track0
Lottery odds40
Fits your clock70
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About the role
- Assigned cases and projects are generally of moderate complexity and performed with limited oversight.
- Job Description - Assist in performing ongoing FWA risk assessments, leveraging data analytics to identify trends, patterns, outliers relative to peers and clinical standards, etc.
- All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.
Responsibilities
- Create and maintain detailed case files in accordance with SIU policies and procedures, where key investigative activities and outcomes are timely and accurately documented
- Perform day-to-day activities for vendor-based claim overpayment recovery program (e.g., data file exchanges, proposing / reviewing new audit concepts, coordinating claim adjustments, invoices).
- Support the FWA training program for Blue KC employees and First Tier, Downstream and Related entities.
Nice to have
- experience analyzing claims data to identify FWA trends and patterns using tools such as Excel and business intelligence platforms (e.g., Power BI, Business Objects).
- Knowledge of major BCBSKC business systems (e.g., Facets, ITS Host and Home) and operational processes (e.g., Claims Processing, Pharmacy, Provider Contracting/Relations, Member Services, Customer Service)
- Experience working with the regulators (e.g., CMS, State Department of Insurance) and law enforcement (e.g., FBI, DEA, HHS-OIG, OPM-OIG and/or Department of Justice)
- Licensed Clinal Social Worker (LCSW)
- Licensed Professional Counselor (LPC)
- Coding Certification: AAPC, AHIMA
- Blue Cross and Blue Shield of Kansas City is an equal opportunity employer.
Compensation
- Annual incentive bonus plan based on company achievement of goals
Benefits
- Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
- Annual incentive bonus plan based on company achievement of goals
- Time away from work including paid holidays, paid time off and volunteer time off
- Professional development courses, mentorship opportunities, and tuition reimbursement program
- Paid parental leave and adoption leave with adoption financial assistance
- In conjunction with the Manager and/or Senior Investigator, evaluate FWA risks and prioritize for further review, based upon member health/safety and protection of plan assets.
- Monitor hotlines, internal referrals, external fraud alerts (e.g., CMS, BCBSA), external healthcare anti-fraud workgroups, and other resources for potential FWA schemes.
- Present reports to key stakeholders (e.g., Provider Relations, Medical Management, Pharmacy, Claims, Legal)
This listing is sourced directly from BCBS's careers page and normalized into a canonical job model.