CT , Wallingford
NY , Albany
Empire Blue Cross Blue Shield, a proud member of the WellPoint family of companies, is a distinguished leader in the health insurance industry. At Empire, we are dedicated to improving the lives of the people we serve and the health of our communities. Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.
Investigator III or Sr Insurance Fraud
Wallingford CT or Albany or NYC NY
Investigator III (E12) is responsible for the identification, investigation and development of complex cases against perpetrators of fraud in order to recover corporate and client funds paid on fraudulent claims, utilizing FBI and other law enforcement resources, and state of the art investigation techniques. Primary duties may include, but are not limited to: Responsible for enterprise-wide specific investigations that may impact more than one WellPoint health plan. Must be able to effectively establish rapport and on-going work relationship with FBI and District Attorney office. Will interface internally with Senior level management and legal department. Must have experience in complex, high dollar white collar and/or healthcare investigations required.
Investigator Sr - (E12) is responsible for investigating, collecting, researching and analyzing billing data in order to detect fraudulent, abusive or wasteful activities/practices. Primary duties may include, but are not limited to: Using appropriate system tools, analyzes data to detect fraudulent, abusive or wasteful payments to providers and subscribers. Prepares statistical/financial analyses and reports to document findings and maintains up-to-date case files for management review. Prepare final report and notification of findings letter suitable for dissemination to provider and counsel. Presents providers offers for settlement to supervisor and legal for approval. Communicates orally and in writing with all customers, internal and external, regarding findings. Assists in the development of policy and/or procedures to prevent loss of company assets. Prepares and delivers training to internal and external entities. Develops and maintains a high degree of rapport and cooperation with the Federal, State and local law enforcement and regulatory agencies which can assist in investigative efforts. Represents the Company in court proceedings regarding research findings. Provides technical support and guidance to lower-leveled associates. Assists with special projects, systems implementations and updates.
Investigator Sr
Requires BA/BS, 3-5 years experience in healthcare, white collar crime investigation or related area; or any combination of education and experience, which would provide an equivalent background.
Investigator III
Requires BA/BS degree, 3-5 years related experience; or any combination of education and experience, which would provide an equivalent background. Prior experience working with FBI, HHS-OIG or Department of Justice, or prosecution experience preferred. Fraud certification from HIAA or NHCAA, RN or JD certification preferred.
Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.
Recent federal law enforcement experience, and/or J.D. degree, and admission to any state bar association and/or clinical pharmaceutical experience is preferred.
Professional certification of CFE, AHFI or other job related designation preferred.
Travel required.
WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, one of the 100 Best Places to Work by Working Mother magazine, and is a 2011 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at www.wellpoint.com/careers. EOE