The Senior Clinical Investigator works closely with the management team to develop investigative strategies and department initiatives. The Senior Investigator leads complex fraud cases and provides guidance to less experienced investigators. The Senior Clinical Investigator demonstrates independence and initiative with respect to proactively identifying risks, conducting investigations, developing and supporting recommended actions, and identifying process improvements that align with corporate strategy.

• Independently reviews and analyzes claims data and other resources to proactively identify potential risks of fraudulent, abusive or wasteful activities and/or practices.
• Independently conduct investigations of reported allegations of fraudulent, wasteful or abusive activity. Prepare statistical/financial analyses and reports to document findings and maintain up-to-date case files.
• Present recommendations to the F&A Committee.
• Negotiate settlement offers and present for management and legal approval.
• Communicate orally and in writing with all customers, internal and externally, regarding findings.
• Recommend and develop department policy and/or procedures
• Provide training to internal and external entities.
• Ability to be comfortable in high stress environments including defending and discussing audit findings with high level executives of large provider facilities and practices, coordinating investigative efforts with law enforcement authorities and working closely with the internal legal department and external council to develop civil cases
• With Legal support, represents the Company in court proceedings.
• Demonstrate leadership ability by coordinating complex cases & provide technical support and oversight.
• Establish standardized auditing tools to be used in multi-provider audits & develop training materials to instruct other investigators in preparation for multi-provider audit.
• Function as the lead investigator for a multi-provider audit & review and analyze complex coding requirements & recommend process improvement initiatives.
• Support corporate system integrity initiatives such as investigating findings pertaining to identified risks & support key Plan business areas in cost containment initiatives & participate in process analysis to identify risks.
• Assist SIU management as assigned.

Experience: 

• A minimum of 5 years’ experience in health care fraud investigations or compensatory level of experience which may include but not be limited to: extensive knowledge of clinical coding including ICD-10, HCPS and CPT coding guidelines, as well as working knowledge of professional and facility payment structures (including revenue codes), group benefit structures, medical policy configuration, coding edits, claims adjudication processes, and Facets configuration. 
• Experience with various software applications including Word, Excel, Power Point, and Power BI.
• Experience in planning, organizing and managing complex fraud cases or initiatives.

Skills:

• Must possess analytical and problem-solving skills.
• Ability to communicate effectively through written and oral communications with a focus on communicating complex issues in an organized concise manner.
• Ability to collaborate & develop working relationships across multiple departments within Capital Blue Cross.
• Ability to quickly gain knowledge of new business processes and issues.
• Ability to adjust to changing priorities and manage time effectively to meet urgent deadlines.
• Flexibility to function independently, ability to prioritize assignments and adjust to rapidly changing business needs without constant supervision.

Education and Certifications: 

• A professional practitioner with an unrestricted license/certification in PA (i.e., Registered Nurse, Certified Nurse Practitioner, Certified Physician’s Assistant, Social Worker, etc.)
• Requires CPC certification or obtain within 12 months of hire and maintain the certification with sufficient CEU requirements.
• Prefer degree in Business, Health Care Management, Criminal Justice or a related field.

 Physical Demands:

• Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions.
• Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor.
• Working environment includes typical office conditions.

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.