Summary
 

Responsible for investigating allegations of fraud/abuse against company and to resolve these allegations through recovery of monies paid improperly as a result of fraud and abuse or billing errors, and to refer fraudulent providers or subscribers to law enforcement for prosecution.

Description
 

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose:

Responsible for investigating allegations of fraud/abuse against company and to resolve these allegations through recovery of monies paid improperly as a result of fraud and abuse or billing errors, and to refer fraudulent providers or subscribers to law enforcement for prosecution.

Location:

This position is full-time Monday - Friday, from 8:30am - 5pm, in a typical office environment. This role is located at 51 Clemson Road, Columbia SC 29229.

Sponsorship:

This position is not eligible for sponsorship now or in the future. 

What You’ll Do: 

• Investigate allegations of fraud, waste, or abuse against the company. Analyze data, obtain and review records from healthcare providers, interview suspects or witnesses, and prepare cases for administrative action and prosecution.
• Draft written reports of investigative findings. Maintain data for reporting purposes. Work with legal department and law enforcement agencies in the prosecution or civil regulation of fraud cases.
• Monitor corporate fraud hotline, web reports and Global Core inquiries. Assist new personnel in activities related to investigative techniques. Monitor restitution payments, track recoupments and savings activities and transfer refund payments received for investigations to the Treasury Department. Assist with the reporting of these tasks within the Special Investigations Unit.
• Assist in creating, updating and maintaining policies and procedures as required. Participates in training, webinars, and conferences as required.

To Qualify For This Position, You'll Need The Following: 

• Required Education: Bachelor's
• Degree Equivalency: 4 years job related work experience or Associate's and 2 years job related work experience
• Required Work Experience: 2 years of fraud investigations or audit in health insurance or other regulatory industry, OR 2 years of law enforcement investigations experience, OR 3 years of experience in a health insurance claims operation.
• Required Skills and Abilities: Strong customer service orientation. Ability to effectively communicate both verbally and in writing to all levels throughout the organization. Excellent analytical or critical thinking skills. Ability to persuade, negotiate or influence. Ability to review, analyze, and develop information and make appropriate decisions. Ability to develop working knowledge of medical terminology. Ability to work independently and prioritize workload. Knowledge of insurance commission regulations. Ability to handle confidential or sensitive information with discretion.
• Required Software and Other Tools: Microsoft office.