Health Insurance Investigator (Open to hiring at the Sr. level)

Company Description

Why Wellmark: We are a mutual insurance company owned by our policy holders across Iowa and South Dakota, and we’ve built our reputation on 85 years’ worth of trust. We are not motivated by profits. We are motivated by the well-being of our friends, family, and neighbors–our members. If you’re passionate about joining an organization working hard to put its members first, to provide best-in-class service, and one that is committed to sustainability and innovation, consider applying today! 

Learn about our unique benefit offerings here. 

Learn about life at Wellmark here.

Job Description

Reporting to the Team Leader of SIU & Compliance, you will identify and investigate suspected provider and member health insurance fraud, waste and abuse, identify potential losses and recoveries for the corporation, prepare reports of suspected fraud, waste and abuse, and work with law enforcement agencies and anti-fraud organizations, as appropriate. Investigations must be conducted in accordance with company policies and procedures and in compliance with all applicable laws and regulations. 

Ideal candidates will have experience in health insurance operations, with a foundational knowledge of applicable rules/regulations and medical terminology, including coding. You have exceptional attention to detail and identify as meticulous and methodical. You do not seek immediate gratification in your work; you embrace patience and are comfortable with dedicating time before you see results. You love to research – whether with existing content or collaborating with other stakeholders. You have excellent written and verbal communication skills and a demonstrated history of building meaningful, professional relationships. You are naturally curious, inquisitive and willing to ask questions to achieve goals focused on the desired outcomes. Analyzing complex information and articulating it in a digestible manner comes easily and you gain energy from a day that requires the evaluations of facts to determine next steps.  

Qualifications

Required:

• Associate degree in related field or direct and applicable work experience.
• 1+ year of experience in Health Insurance operations including applicable rules/regulations, or related experience.
• Ability to follow procedures for identifying, reporting and preventing fraud, waste and abuse.
• Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes.
• Demonstrated analytical skills to recognize inconsistencies, research, obtain information from multiple sources and come to a conclusion.
• Ability and willingness to approach complex problems from different angles and produce creative, innovative solutions while ensuring compliance with laws and internal procedures.
• Skilled at researching and using appropriate interaction skills and methods to come to conclusions.
• Strong verbal and written communication skills with the ability to articulate complex information clearly and concisely while maintaining courtesy and professionalism to a variety of stakeholders, both internally and externally.
• Ability to work with others in difficult and complex situations to achieve resolution or adherence to laws and/or regulations
•  Ability to organize and manage multiple conflicting priorities in a dynamic work environment. Prior experience using Microsoft Office applications such as Word, Excel  and/or Outlook and the ability to learn new systems quickly.
• Travel required up to 5%

Preferred:

• Experience in fraud, waste and abuse investigations.
• Experience in facilitating presentations/trainings.
• Ability to navigate and thrive in ambiguous situations, effectively adapting to changing priorities and making informed decisions with limited information.

Additional Information

a. Evaluate allegations of fraud and abuse from members, providers, other Plans and law enforcement by utilizing data analysis tools such as existing Business Objects reports, fraud software, and web-based searches. Analyze, assemble observations and document findings to make recommendation to leadership of next steps. Maintain comprehensive case file documentation to support case.

b. Utilize fraud, waste, and abuse detection software, other data sources, and leads to identify or substantiate patterns of suspected irregular health insurance activity proactively.

c. Analyze data and develop investigation plan to determine what medical records or other supporting documentation is needed and how it will be reviewed.

d. Determine if provider and/or member interviews are needed, develop script and conduct interviews.