Global Healthcare Fraud Investigator

Responsibilities

• Evaluate and gather information related to cases of known or suspected fraud.
• Analyze historic claims to determine the full scope of identified fraudulent activity.
• Develop an investigation strategy for each case to assist in timely and successful resolution.
• Conduct interviews/interrogations with customers, providers, witnesses, authorities, and other people involved in the case.
• Document your activities in a logical, clear, and concise format, concluding with a comprehensive written investigation report.
• Facilitate the recovery of fraud and abuse related over payments of company and customer funds.
• Collaborates with law enforcement agencies as appropriate, including potentially testifying to investigation details in court.
• Researches and prepares information for management and client reporting.
• Collaborate with other departments (e.g., Clinical, Legal, Provider Finance, Global Service Center, Claims) and external entities (e.g., BlueCross Blue Shield home plans, law enforcement).
• Partner with legal and compliance to ensure all state, federal, and international requirements for investigations and fraud reporting are adhered to.
• Identify and deliver on continuous improvement opportunities.

Requirements

• College degree or equivalent experience required.
• Fraud examination certification or equivalent credentials highly valued.
• Minimum 2 years of investigation experience or 4 years of insurance industry experience required; 5-7 years preferred.
• Demonstrated experience conducting international health insurance fraud investigations strongly preferred.
• Strong attention to detail and problem-solving skills.
• Excellent written and verbal communication skills.
• Strong organizational skills, with the ability to manage multiple competing tasks at the same time.
• Able to manage ambiguity and drive for resolution.
• Multilingual strongly preferred.