Investigative Analyst - 240201

DESCRIPTION/RESPONSIBILITIES: The CFID Support team is charged with the identification, tracking and remediation of many allegations of FWA.  These activities may include the decision to request medical records, retract claims, request repayments and refer the matter to the Investigative team.  Additionally, this team conducts proactive analysis of paid claims data and other related data, to decide what entities should be pursued through audit or investigation.

• Research and remediate allegations of FWA by pulling claim detail and medical records reviewing the claim to determine if  the claim was paid per plan guidelines and subscriber's benefits. 
• If this associate determines there is a billing error, the claim is sent for retraction through an inquiry in INSINQ.  If this associate determines there is a coding error, works with the provider/claims area to ensure the claim is resubmitted for appropriate payment.
• If the associate suspects fraud, the allegation is sent to the Investigation Unit along with all supporting documentation and claims analysis for consideration for legal actions.
• Medicare allegations are forwarded for reporting purposed to MAG area and allegations are forwarded from MAG area for CFID handling, after determination is made the decision (claim retraction, PHI issue, coding issue etc..) is reported to MAG to send closeout letter to subscriber.
• This associate is independently making decisions on claim retractions and the routing of inquiries to the investigative unit.
• Working with Senior Analyst on Proactive review of data to find potential cases of Fraud, Waste and Abuse. This associate determines which findings are presented at monthly meetings and/or sent to the Investigation Managers or the Payment Integrity team for possible Cases and/or Audits, and which issues do not rise to the level of this review. 
• This associate work with the Senior level analyst to decide whether these issues are handled through provider notifications, requests for repayment or claim offsets/retractions. Outlining issues are sent to areas for claim edits or medical policy edits.
• Review cases to identify trends and claim payment spikes -- look for issues such as multiple complaints from same provider, review of provider billing pattern over the past years looking for spikes or anomalies. 
• Receive "SIU (Special Investigation Unit) Alerts" from other plans.   Using Informant - a database pulled from our data warehouse containing claims grouped by provider - pulls our claims to determine if there are any trends in our data related to the SIU alert. 
• Health Care Fraud Shield (an external web-based application) scores providers on areas such as unbundling of claims, billing spikes, and atypical claims bundling.  Using this information, reviews IBC internal data for these providers to determine if we are seeing the same trending against provider peers. Scores providers on areas such as unbundling of claims, billing spikes, and atypical claims bundling.  Using this information, reviews IBC internal data for these providers to determine if we are seeing the same trending. 
• This associate is independently making decisions whether to pursue and remedy issues identified during these reviews, to include requesting medical records, retracting claims, requesting overpayments or referring to the investigative team
• Request medical records, make inquiries or request adjustments across all plans.  Primary user of Blue Square system to request medical records, make inquiries or request adjustments all Blue plans.
• If a complaint and subsequent review results in a determination that the claim should not have been paid, the claim is traced to ensure that the overpayment dollars are returned to IBC by the provider.  Process offsets and check payments for recoveries. The analyst recoveries for the month are reported after retractions and offsets are complete to ensure accurate m nthly financial reporting.  If provider decides to send physical check the Specialist will be given g/l coding and deposit information for handling. Do not handle physical checks.
• Utilize CFID systems (Informant, FraudShield, INSINQ) to assign member flags when a member calls to report that their card was lost or stolen or PII was compromised.  Monitor claims for flagged members for 90 days to ensure there is no fraudulent activity.
• Other duties as assigned

QUALIFICATIONS: * 3-5 years of relevant experience.  * High School degree or equivalent. * Working toward a Certification in Fraud Analysis preferred . * Has in-depth knowledge in own discipline and extensive knowledge of related disciplines such as claims payment system, benefit analysis, medical policy and provider contracts. * Based on analysis and research initiates claim offsets, retractions and demand letters for provider repayment agreements. * Solves complex problems; takes a new perspective on existing solutions such as claims payment edit updates, medical policy change and provider contract/third party issues.  * Works independently; receives minimal to no guidance.  Acts as a resource for colleagues with less experience and peers 

Equal Employment Opportunity

Independence Blue Cross is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.