Job Description

About Blue Cross and Blue Shield of Minnesota

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

The Impact You Will Have

In this position, you will be responsible for the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse and over-payment recovery cases. This includes gathering, analyzing and interpreting complex data and information to provide meaningful results in developing leads, collaboration with internal resources as well as complying with state and federal requirements for fraud, waste and abuse detection and prevention.

What You’ll Do

• Analyze and triage referrals/leads and determine appropriate research/investigation needed with minimal guidance. Proactively identify, analyze, investigate and evaluate moderate to complex potential fraud, waste, or abuse, including pre-pay and/or post-pay medical claims reviews to determine valid cases for appropriate action; document findings, and prepares case referrals, letters, and reports.
• Conduct interviews of patients, providers, provider staff and other witness/experts.
• Utilize clinical expertise, health plan knowledge, and claims analysis to review and assess medical records for appropriateness.

How You’ll Do It

• Represent Blue Cross by testifying at trials, offering depositions and responding to subpoenas.
• Prepare for and facilitate settlement negotiations with providers, attorneys and other responsible parties with minimal supervision.
• Document case activity, and fund allocation and conduct follow-up-actions in a timely manner following documented departmental guidelines.
• Refer well documented and substantiated cases to law enforcement agencies which may include the Federal Bureau of Investigations (FBI), the Office of the Attorney General (OIG) and local police departments.
• Meet all contractual, State and Federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS and other agencies.
• Performs additional responsibilities consistent with the scope and level of the role, as assigned.

Required Skills & Experience

• 3+ years of related healthcare, operations auditing/investigations, professional experience.
• Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the qualifications listed above may be accepted.
• Ability to travel during the workday and potential overnight travel.

Preferred Skills & Experience

• Ability to tailor communication to varied audiences, actively listen to uncover requirements, and ensure accurate and timely information exchange.
• Ability to analyze information, identify patterns and root causes, and collaborate with partners to implement practical solutions.
• Ability to effectively organize work, balance competing priorities, and manage time across multiple responsibilities and deadlines.
• Healthcare or health insurance industry experience.
• Previous non-financial audit experience.
• Knowledge of industry audit standards and statistical sampling.
• Analytic, writing and reasoning skills, including the ability to evaluate complaints, referrals and health care data laws and regulations and relevant federal laws and regulations, including but not limited to HIPAA.
• Knowledge of and ability to comply with applicable federal, state, and local employment laws, regulations, and compliance requirements.
• Ability to maintain discretion and confidentiality.

Licensure/Certifications

Required: Registered nurse or licensed behavioral health clinician (i.e. LICSW, LPCC, LMFT, LP, LADC, LBS, BCBA) with current MN license and no restrictions or pending restrictions.

Role Designation

Hybrid

Anchored in Connection

Our hybrid approach is designed to balance flexibility with meaningful in-person connection and collaboration. We come together in the office two days each week – most teams designate at least one anchor day to ensure team interaction. These in-person moments foster relationships, creativity, and alignment. The rest of the week you are empowered to work remote.

Compensation and Benefits:

Pay Range: $68,900.00 - $91,300.00 - $113,700.00 Annual

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

To discover more about what we have to offer, please review our benefits page.

Equal Employment Opportunity Statement

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. Blue Cross of Minnesota is an Equal Opportunity Employer and maintains an Affirmative Action plan, as required by Minnesota law applicable to state contractors. All qualified applications will receive consideration for employment without regard to, and will not be discriminated against based on any legally protected characteristic.

Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talent.acquisition@bluecrossmn.com.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

Physical Requirements