Special Investigation Analyst

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Detroit, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.&nbsp;<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />For Application Timeline &amp; Selection Process:&nbsp;<a href="https://s3.amazonaws.com/data.vizirecruiter.com/Images/BCBSMCareers+-+Quick+Reference+Guide.pdf" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="https://ejko.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_3/requisitions" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

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Competitive Total Compensation Package

Overview: Responsible for the collection, evaluation and preparation of internal data and/or documents in support of field investigation related to suspected fraudulent claims. Resolve non-prosecutable analyst cases and prepare and maintain department investigative files and case information systems. Assist in planning and special project activities as required by the Director, Manager and Lead Investigative Analyst.<br /> <p><strong><em>DEPARTMENTAL SUMMARY:</em></strong></p> <p>This position will be responsible for pro-active data mining using vendor software as well as self-created ad-hoc queries.&nbsp; It requires a dynamic, critical thinker who is a self-starter responsible to lead projects, identify gaps, propose and drive process changes.</p>
Responsibilities: <ul> <li> <div>Analyze and prepare reports such as claim/member data analysis using Access, Cognos IQ and Data Analyzer.</div> </li> <li> <div>Financial analysis to compile corporate loss and/or court restitution activity.</div> </li> <li> <div>Resolve non-prosecutable inquiries and/or cases such as ineligible dependents and billing/processing errors.</div> </li> <li> <div>Communicate directly with law enforcement personnel at the request of the Fraud Investigator. Provide on the job training to Fraud Investigators and Fraud Investigation Manager and technical knowledge of Blue Cross Blue Shield of Michigan (BCBSM) products, policies and procedures. Train Fraud Investigators on the analysis and interpretation of all claims systems and/or transactions and BCBSM utilization files and/or field descriptions.</div> </li> <li> <div>Provide investigative staff support through the research, collection, and evaluation of data and the summation of policies concerning benefits, membership, reimbursement, provider enrollment, etc.</div> </li> <li> <div>Maintain specialized department files which include Corporate Recovery referrals, Federal Register Provider Exclusion List, Pre-payment Utilization Review files, Departicipation files and corporate files.</div> </li> <li> <div>Assist in project development and data gathering on new projects.</div> </li> <li> <div>Act as a liaison with other BCBSM departments and represent department on various task forces and work groups.</div> </li> <li> <div>Research and prepare special studies as required.</div> </li> <li> <div>Other duties may be assigned.</div> </li> </ul>
Requirements: <ul> <li>Bachelor's Degree in Business Administration or related field preferred.</li> <li>Four (4) years BCBSM analytical work experience.</li> <li>Excellent analytical, organizational, problem solving, verbal and written communication skills.</li> <li>Proficient in current industry standard PC applications and systems.</li> <li>Thorough knowledge in all BCBSM lines of business, including but not limited to, product knowledge, benefits, utilization and membership.</li> <li>Thorough knowledge of claims benefits for all lines of business, i.e. facility, regular business, dental/vision/hearing, drugs, etc.</li> <li>Extensive knowledge of corporate data files, including paid claims, utilization data, membership and provider files on all systems (FEP, Local, Merck-Medco, NASCO, STAR).</li> <li>Extensive knowledge of data processing with the ability to utilize data from various sources.</li> <li>Other related skills and/or abilities may be required to perform this job.</li> </ul> <br /> <p><strong><em>DEPARTMENTAL REQUIREMENTS:</em></strong></p> <ul> <li><em>Bachelor&rsquo;s Degree in Data Science, Data Analytics, Statistics, Computer Science, or Mathematics highly preferred.&nbsp; Master&rsquo;s Degree a plus.</em></li> <li><em>Skilled in query building, programming and using visualization tools (i.e. SQL, SAS, R, Toad, Python, Tableau, etc.).</em></li> <li><em>Proficient in Microsoft *Access, Word, *Excel, and PowerPoint.&nbsp; *Highly used in this role.</em></li> <li><em>Clinical experience preferred</em></li> <li><em>Audit experience preferred</em></li> <li><em>Certified Professional Coder (CPC) would be a plus</em></li> </ul> <div id="gtx-trans" style="position: absolute; left: 257px; top: 235px;">&nbsp;</div>