Program Integrity Analyst/Investigator Clinical - Behavioral Health

Fraud, Waste, Abuse Investigator 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. 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. 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.