Medical Practice Investigation Specialist

Under limited supervision, the medical practice investigations specialist will play a critical role in detecting and preventing healthcare waste and abuse to optimize network integrity. The investigator will utilize various investigative techniques to manage and conduct activities related to capture, analysis, and correlation of substantial amounts of claims data to identify anomalous medical practice patterns that result in significant fiscal impact to the company and/or healthcare impact to the member.

"Upon completion of the initial six-month training period, this position will be eligible for hybrid work. After the training is completed, employees may choose to work onsite or in a hybrid capacity (a minimum of 9 days per month onsite), in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment."

Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

Why Join Us

• Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.

• Professional Growth Opportunities: Advance your career with ongoing training and development programs.

• Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.

• Trust: Work for one of the most trusted companies in Kansas

• Flexibility: options to work onsite or hybrid available

• Inclusive Work Environment: We pride ourselves on fostering a diverse and inclusive workplace where everyone is valued and respected.

Compensation

$30.11 - $35.80 hourly
Non-Exempt 14

• Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid.  All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.
   

What you’ll do

• Performs investigations into potential and existing providers which includes reviewing claims data, medical reviews, provider files, etc. and utilizing data analysis techniques to detect irregularities, billing trends, and financial relationships in BCBSKS claims data to detect potential wasteful or abusive billing practices or vulnerabilities in the BCBSKS provider network. Conducts telephone and/or in person interviews with members and/or providers and/or provider staff to determine the validity of claims filed in the furtherance of an investigation or case.

• Utilize and validate data analysis results and analytically identify potential waste and/or abuse situations in violation of Medicare/Medicaid laws, guidelines, policies, and regulations. This includes proactively seeking out and developing leads/cases from a variety of sources including CMS and OIG, internal alerts, and referrals from external parties.

• Analyze information gathered during the investigation for potential patterns of anomalous medical practice and prepare a detailed written summary of findings and recommendations for potential corrective action. Validation and analysis of data requires extensive use of industry standard code sets (ICD10, CPT, HCPCS etc.). This information is presented to senior management, as necessary.

• Identifies and investigates anomalous medical practice patterns or inappropriate utilization by conducting pre-payment reviews and post payment audits of claim activity by providers as needed. To include requesting and reviewing medical records.

• Collaborates with departments and all levels of staff through the organization to foster a partnering-based approach to investigations and anomalous medical practice pattern identification activities with sub-contractors, vendors, and other covered entities. This includes engaging other risk management functions and/or forwarding cases as needed to internal committee teams.

• Assists in the development of new methods, processes, and programs to analyze and report medical practice information. Recommend changes to medical policy, provider manuals, policy memos, and provider workshops. Assists in maintaining departmental processes and procedures.

• Assists in providing education to providers on proper billing and documentation requirements.

• Respond to requests for information from provider licensing board, State Insurance Departments, and law enforcement agencies.