Provides Plan and PBM oversight for the identification, investigation, and reporting of FWA. Coordinates and facilitates single and multi-Plan investigative efforts. Conducts training as required. Participates in special projects as required. Conducts research relating to FWA and participates in the training of vendors and Plans. Assists internal/external entities with various types of litigation support. Supports various FEP SIU systems. Interacts with various areas of BCBSA regarding issues identified through investigations and reviews. Provides Plan/PBM oversight for the identification and investigation of non-compliance issues. Monitors and ensures Plan/PBM compliance with internal systems and programs. Coordinates and facilitates single and multi-Plan/PBM investigative efforts. Develops and participates in special projects as required. Lead or support various Anti-Fraud projects through the year as determined by the business.

Job Description

• Provides FWA program oversight to enhance BCBS FEP investigations and training opportunities related to OPM OIG Carrier Letter reporting requirements, FEP SIU Tracking System (FSTS) compliance, and other internal systems and program requirements.

• Coordinates and facilitates single and multi-Plan/PBM investigative efforts. Presents documentation and other factual material for referral to OPM-OIG and other local, state, federal law enforcement and prosecutorial agencies.

• Supports Plan/PBM SIUs and OPM-OIG in working FEP health care FWA investigations. Leads proactive special projects in support of FEP SIU and organizational goals to include identifying health care fraud schemes and trends.

• Responsible for working with and advising BCBS Plans/PBMs. Develops, facilitates, and delivers compliance training regarding FEP contract performance, as well as expectations of OPM and OPM-OIG.

• Maintains and cultivates good working relationships with various local, state, and federal agencies by attending task force meetings, participating in working groups. Delivers presentations to various stakeholders.

• Provides program improvement recommendations in the area of fraud detection and investigation services in support of the Federal Employee Program (FEP) Anti-Fraud Programs.

• Analyzes FEP claims data to develop health care fraud investigations for referral to various parties including federal, state and local authorities, Blue Plan anti-fraud units and internal and external FEP departments.

• Responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities committed against FEP by health care providers/facilities/members and others.

• Provides recommendations for program edits and policy changes to mitigate FWA.

Education

Bachelors Degree
Bachelor's degree in criminal justice, healthcare, intelligence, business, compliance or related discipline or equivalent experience is required.


Certifications

Certification as an Accredited Health Care Fraud Investigator or a Certified Fraud Examiner


Experience

3 years of any of the following; fraud investigations, intelligence, business, and compliance experience.


Skills

Essential - Analyzing and responding to complex data and/or the processing of information requests.

• Technical proficiency in the use of various computer software programs including Microsoft Windows, Microsoft Office (Outlook, Word, Excel, PowerPoint).
• Excellent organizational and time management skills.
• Analytical skills: Capability to research and analyze data/information and apply it appropriately and accurately in the resolution/response to questions/inquiries.
• Strong skills in the areas of compliance and the ability to interpret written materials.
• Strong interpersonal skills and relationship development abilities are essential, as well as demonstrated customer service skills.
• Excellent verbal and written communication skills.
• Preferred Qualifications:
• Prior federal, state, or local law enforcement experience.
• Prior experience in Anti-Fraud environments in the healthcare industry.
• Knowledge of federal government investigative agencies and subcontractor relationships

People Management

No