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Role Description

As a member of Premera’s Special Investigations Unit (SIU), the Investigator III leads complex investigations into allegations of external fraud, waste, and abuse (FWA). This role manages medium to high complexity cases from initiation through resolution, producing thorough, well-documented investigative reports that may be subject to legal discovery. The Investigator III conducts detailed analysis, collaborates closely with SIU colleagues, and balances multiple investigations simultaneously. In this role, you will also work to identify and recover improper payments resulting from fraudulent or misrepresentative billing, while ensuring all investigative activities comply with company policies, regulatory requirements, and applicable laws.

• Analyze healthcare claim data and vet referrals to detect fraudulent activity and independently determine the most effective and efficient method of investigation for each individual case.
• Perform investigative field work to include on-site office visits, record collection, and surveillance.
• Interview suspects and witnesses.
• Prepare cases, testify and give depositions to law enforcement and regulatory agencies for potential criminal prosecution.
• Participate in settlement negotiations with attorneys and other responsible parties.
• Perform root cause analysis of identified issues and prepare post-investigative reports directed towards the prevention of fraud.
• Make recommendations for creating SIU policies, procedures, workflows and process improvements.
• Develop and maintain collaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA), Blue Cross Blue Shield (BCBS) Plans, HHS OIG, other carriers' anti-fraud professionals, law enforcement and regulatory agencies.
• May attend webinars and conferences like BCBSA, National Health Care Anti-Fraud Association (NHCAA), and Association of Certified Fraud Examiners (ACFE) to keep apprised of developments in health care fraud.

Qualifications

• Bachelor’s degree in business administration, health care administration, finance, accounting, nursing or criminal justice or (4) years of work experience in field of study. (Required)
• (3) years of experience in fraud investigation, special investigation unit, or a related field. (Required)
• Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI).
• Two (2) years of active experience in auditing and investigating in the healthcare industry.
• Significant experience with relevant technology, such as background check systems, claims processing platforms, data mining, and fraud detection software.
• Demonstrated knowledge of institutional and/or professional payment methodologies.
• Strong understanding of health insurance reimbursement methodologies, including familiarity with International Classification of Diseases (ICD-10 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS).
• Strong computer aptitude and experience with spreadsheet and database software, e.g., Excel, Access, Focus.
• Demonstrated strong technical writing skills - ability to write reports and business correspondence and to prepare case files.
• Ability to exercise a very high level of discretion when handling sensitive information.

Benefits

• Medical, vision, and dental coverage with low employee premiums.
• Voluntary benefit offerings, including pet insurance for paw parents.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service.
• Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs.
• Generous paid time off to reenergize.
• Tuition assistance for both undergraduate and graduate degrees.
• Employee recognition program to celebrate anniversaries, team accomplishments, and more.
• For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
• Commuter perks make your trip to work less impactful on the environment and your wallet.
• Free convenient on-site parking.
• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
• Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.