Fraud Analyst

Summary
 Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Description
 

***This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. ***

Position Purpose:

Responsible for conducting investigations of complaints of irregular activity by evaluating, reviewing records, and analyzing information. Performs compliance/fraud related investigations. Communicates with providers, beneficiaries and/or suppliers as a major function of the position.

Logistics:

This position will be fully onsite located at 8733 Highway 17 Bypass, Myrtle Beach, South Carolina 29575.

What You'll Do:

• Performs screening of complaints. Determines developmental actions needed to resolve the complaint by contacting provider/facility, requesting medical records, or contacting beneficiaries. Determines the classification of the fraud complaint and the steps needed to determine the validity and to resolve the complaint. Assigns the complaint to the investigation staff member based on independent judgment and an analysis of the developed facts. Responds to beneficiary and provider telephone inquiries. Inputs initial fraud complaints information in the fraud and abuse case tracking system database for future case development and analysis. Coordinates with management and appropriate entity as necessary.

• Investigates complaints by communicating with beneficiaries and providers and researching claims/medical data. Research facts and closes the complaints based on information gathered, collects overpayments, educates providers and beneficiaries, or refers cases to the appropriate entity for investigation. Compile monthly and quarterly reports in a timely and accurate manner.

• Establishes and maintains working relationships with internal and external sources of expertise for coordination of initial case development. May address Hotline complaints. Elicits necessary case initiation information from suppliers and determines the validity of the allegations.

• Attends training workshops and seminars to remain abreast of the most current laws and regulations.

To Qualify for This Position, You’ll Need:

Required Education:

• Bachelor's

Degree Equivalency:

• Associate's plus 2 years job related work experience for a total of 3 years required experience.

OR

• 5 years of related work experience.

Required Work Experience:

• 1 year customer services, research/analysis, claims processing, education/training, medical affairs, or healthcare program management.

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 and problem-solving skills.

• Ability to persuade, negotiate or influence.

• Ability to review, analyze, and develop information and make appropriate decisions.

• Working knowledge of or the ability to learn medical terminology.

• Ability to work independently, prioritize workload, organize daily itinerary and travel.

Required Software and Tools:

• Microsoft Office.

Preferred Education:

• Bachelor's degree- Criminal Justice, Healthcare, Healthcare Administration, Health Promotion or Public Health.

Preferred Work Experience:

• 3 years-auditing/compliance, healthcare program management, investigation and fraud preventions.

Preferred Software and Other Tools:

• Experienced with reporting, Microsoft Excel, Access or other database software.

Preferred Licenses and Certificates:

• Certified Fraud Examiner (CFE), or Accredited Healthcare Fraud Investigator (AHFI).

What We can Do for You:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage

• 401K retirement savings plan with company match

• Life Insurance

• Paid Time Off (PTO)

• On-site cafeterias and fitness centers in major locations

• Wellness program and healthy lifestyle premium discount

• Tuition assistance

• Service recognition

• Employee Assistance

• Discounts to movies, theaters, zoos, theme parks and more

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure your meet the qualifications.  This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. If the qualifications required proof of semester hours, please attach your transcript to your application.

Management will be conducting interviews with the most qualified candidates, with prioritization give to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information. 

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.