Resp & Qualifications
PURPOSE:
The SIU Forensic Data Analysis position works to consume, standardize, and interpret data and information to meet evolving operational and client needs. The position requires the preparation of statistical/financial analysis reports and graphic presentation for notification of findings. This position is a power user of the assigned data software in detecting and investigating provider and member leads for investigation of potentially fraudulent or abusive billing, claims patterns, and/or other outliers requiring further analysis by SIU, Management and Investigators.
ESSENTIAL FUNCTIONS:
- Perform data analytics to identify fraud, waste or abuse in claims data. Proactively identify instances of potential fraud, waste and abuse through data analysis using company systems and tools. Utilize knowledge of healthcare coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies and relevant laws to find suspicious patterns in claims data and other sources. Develop and maintain general knowledge healthcare reimbursement policies and state and federal regulations related to healthcare fraud and abuse.
- Provide comparative analysis of data and apply it to external audit methodology and operational/business needs. Collaborates with departmental staff, management and other internal departments to collect and analyze corporate records as directed by management. Assist Investigators and staff in preparing cases for referral to OPM-OIG for potential criminal or civil litigation when appropriate. Work with BCBSA Consultant in supporting that cases are referred to the OPM-OIG in accordance with Contract CS 1039 and the Carrier Letters.
- Extract complex formulated data from corporate systems and produce operational ad-hoc reports for use in conducting audit examinations of providers. Communicate results of reports in both verbal and written form to all levels of the company as well as to external entities when required and appropriate.
- Gathers and conducts forensic analysis of corporate records and related billing data to build profiles of individuals or groups potentially participating in fraud, waste or abuse against CareFirst. Performs complex data retrieval and analysis relating to professional, facility, pharmacy and vendor billing histories. Researches and prepares summaries of medical and payment polices for use by Investigators. Compiles findings, recommendations and conclusions into financial investigative reports. On occasion will accompanying Investigators on interviews of subjects and key witnesses. Performs other duties as necessary or appropriate to position.
QUALIFICATIONS:
Education Level: Bachelor’s Degree in Business, Healthcare Analytics, Mathematics, Statistics or related field.
Experience: 5 years in data analysis and report design or the equivalent combination of education and experience.
Preferred Qualifications:
Certified Health Data Analyst (CHDA®), Credentials as Certified Fraud Examiner (CFE), Accredited Health Fraud Investigator (AHFI), or Certified Professional Coder (CPC). In depth knowledge of corporate and divisional policies and procedures, claims processing, underwriting, medical policies, enrollment and billing and/or other related systems and procedures to determine the integrity of claims’ payments and business operations within CareFirst or previous experience in the healthcare industry.
Knowledge, Skills and Abilities (KSAs)
- Demonstrated experience with Microsoft Office products and strong Excel skills
- Excellent oral/written communication and interpersonal skills
- Provides consulting and analytic services to leadership
- Perform analytic tasks for internal or customer specific projects
- Experience with report writing and business correspondence
- Ability to coordinate activities with varying levels of management, staff, external agencies, and medical professionals through strong verbal and written communications
- Evaluate and preprocess raw information
- Ability to plan, organize, and manage projects with minimal supervision
- Ability to deliver results within agreed upon timeframes
- Highly motivated, with strong drive, team spirit, and organizational skills
- Proven judgment, analytical, decision making, and problem-solving ability
- Demonstrate ability to comprehend Federal/State law and desire to further knowledge with additional education
- Ability to handle highly confidential and sensitive information while ensuring compliance with the Company’s privacy policies
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $63,144 – $125,411
Salary Range Disclaimer
Salary will be based on education, location, experience, certifications, etc. In addition to your salary, CareFirst offers benefits such as a comprehensive benefits package, incentive and recognition programs, and 401k contribution (all benefits are subject to eligibility requirements).
Department
Department: Special Investigations Unit
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
#LI-LJ1