Investigator III

Join Our Team: Do Meaningful Work and Improve People's Lives

Our purpose, to improve customers' lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we're creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives! As a result of these efforts we are proud to share that Forbes ranked Premera among America's 2023 Best Midsize Employers (~~~) and America's 2023 Best Employers By State (~~~) .

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As a member of Premera's Special Investigations Unit (SIU), the Investigator III will be responsible for investigating allegations of external fraud, waste, and abuse (FWA). The reports prepared by this position are potentially discoverable material, so accuracy and close attention to detail are vital. In this role, you will initiate, analyze, develop, and successfully complete and resolve fraud investigations of medium to high level complexity. You will perform multiple high-quality investigations concurrently and work in a collaborative environment with other SIU personnel to perform analysis and obtain analytical information of significance to support case investigations. You will also coordinate efforts to recover erroneous payments made due to misrepresentative billing, fraud, or another criminal acts.

This is a hybrid role, with some onsite days required. You must live within driving distance of our Mountlake Terrace campus, located about 15 miles north of Seattle, Washington.

What you'll do:

• Analyze healthcare claim data and vet referrals to detect fraudulent activity and independently determine the most effective and efficient method of investigation for each individual case.

• Perform investigative field work to include on-site office visits, record collection, and surveillance.

• Interview suspects and witnesses.

• Prepare cases, testify, and give depositions to law enforcement and regulatory agencies for potential criminal prosecution.

• Participate in settlement negotiations with attorneys and other responsible parties.

• Perform root cause analysis of identified issues and prepare post-investigative reports directed towards the prevention of fraud.

• Make recommendations for creating SIU policies, procedures, workflows, and process improvements.

• Develop and maintain collaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA), Blue Cross Blue Shield (BCBS) Plans, HHS OIG, other carriers' anti-fraud professionals, law enforcement, and regulatory agencies.

• May attend webinars and conferences like BCBSA, National Health Care Anti-Fraud Association (NHCAA), and Association of Certified Fraud Examiners (ACFE) to keep apprised of developments in health care fraud.

What you'll bring:

• Bachelor's Degree in Business Administration, Healthcare Administration, Finance, Accounting, Nursing, or Criminal Justice, or (4) years of work experience in field of study. (Required)

• (3) years of experience in fraud investigation, a special investigation unit, or a related field. (Required)

• Registered Nurse (RN), Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI) preferred.

• (2) years of active experience in auditing and investigating in the healthcare industry preferred.

• Law enforcement or government plan auditing experience preferred.

• Strong understanding of health insurance reimbursement methodologies, including familiarity with International Classification of Diseases (ICD-10 CM), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

• Strong computer aptitude and experience with spreadsheet and database software, e.g., Excel, Access, Focus.

• Demonstrated strong technical writing skills to generate reports and business correspondence and to prepare case files.

• Experience with relevant technology, such as background check systems, claims processing platforms, data mining and fraud detection software.

• Able to exercise a very high level of discretion when handling sensitive information.

• Comprehensive knowledge of regulations and laws pertaining to insurance fraud and judicial processes relating to fraud prosecutions.

• Excellent communication, negotiation, and interrogation skills.

What we offer

• Medical, vision and dental coverage

• Life and disability insurance

• Retirement programs (401K employer match and pension plan)

• Wellness incentives, onsite services, a discount program and more

• Tuition assistance for undergraduate and graduate degrees

• Generous Paid Time Off to reenergize

• Free parking

Equal employment opportunity/affirmative action:

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at ~~~ or via phone at ~~~.

Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin .

The pay for this role will vary based on a range of factors including, but not limited to, a candidate's geographic location, market conditions, and specific skills and experience.

National Salary Range:

$67,800.00 - $98,400.00

National Plus Salary Range:

$67,800.00 - $112,200.00

_*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska_ .

At Premera, we make healthcare work better. By focusing on improving our customers' experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives.

As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services.

Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.