Excellus BCBS

Medical Investigator I/II (RN

Buffalo, New York, United States of America · Mid

Sponsorship not specifiedDetected 115 days ago

NegotiationExcelProcess ImprovementRecruitingICD-10FDA RegulatoryResearchLeadershipCommunicationMentoringWritingClaims Management

About the role

Job Description: Summary: Under the guidance of the SIU Management, this position is responsible for the accurate and thorough clinical investigation of potential fraud, waste and abuse (FWA) for all lines of business.
Essential Accountabilities: Level I Functions as a clinical reviewer of medical records, researching and investigating complex medical cases.
Evaluates situations accurately and interacts with management, medical directors and legal, where appropriate, to ensure complex issues are addressed appropriately.

Thoroughly researches allegations or issues and develops sources of information to create a plan of action, accumulates sufficient detailed evidence including statements, documents, records and exhibits.
Manages cases as assigned, prioritizing case load as appropriate.
Maintains case logs, prepares records and regular status reports.

or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies
or an associate's or bachelor's degree in criminal justice or related field

Current CPC designation or must obtain CPC designation within one year of hire date.
Demonstrates proficient computer skills in Word, Excel, Internet, and email.
Ability to multi-task and balance priorities.
Excellent interpersonal skills.
Expertise in the technology of the job.
Excellent ability to determine State and Federal fraudulent activity and compile necessary documentation for prosecution presentation.
Ability to explain and interpret these findings to law enforcement authorities in a comprehensive manner.
Extensive experience with claims processing systems, claims flow, adjudication process, system edits and display screens.

Level I (E2): Minimum: $62,400 - Maximum: $96,081 Level II (E4): Minimum: $65,346 - Maximum: $106,929 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position.
Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity.
The posted salary range reflects just one component of our total rewards package.
Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team.
This decision is made on a case-by-case basis.
One I.D.E.A. One you.

Level I Functions as a clinical reviewer of medical records, researching and investigating complex medical cases.
Interacts with health care providers, often under adverse conditions due to discovery of potential FWA.

Employer Compensation Range(s): Level I (E2): Minimum: $62,400 - Maximum: $96,081 Level II (E4): Minimum: $65,346 - Maximum: $106,929 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position.
Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity.
The posted salary range reflects just one component of our total rewards package.
Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

This listing is sourced directly from Excellus BCBS's careers page and normalized into a canonical job model.