Special Investigator

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

BCBSNE is happy to offer three work designations for our Omaha area employees: in-office, hybrid, and remote.
If choosing to work remote, this role can be located in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas.

This position requires a highly motivated person to be responsible for researching and responding to complaints from subscribers, providers and group representatives. This person would be the initial contact person and initial decision maker for a majority of fraud tips. They would correspond with the provider and members via telephone, letters, email and/or fax. In addition, they would assist to investigate allegations of fraudulent activities perpetrated by health care providers, facilities, subscribers, brokers and/or employer groups. They would be responsible for initiating, analyzing, developing and successfully completing and resolving fraud investigations of mid-level complexity.

What you'll do:

• Investigate, identify, prioritize and answer inquiries from hotline, flagged claims, questions from other departments including CSC, Claims, Benefits and Medial Support Department, and external sources.

• Gathering and analyzing data and information.

• Interact and collaborate with other departments in resolving problems and developing positive relationships.

• Research complaints and claims using various BCBSNE systems.

• Assist and open entry level case work.

• Attend conferences and seminars to keep apprised of developments in health care fraud.

• Participate in internal and fraud specific workgroups

To be considered for this position, you must have:

• Bachelors degree in Business, HealthCare, or related field

• One to two (1-2) years of investigative experience involving health care fraud

The strongest candidates for this position will also possess:

• Coding, billing, processing or auditing of healthcare claims.

• Data analysis

• Certification/License/Education in one or more of the following: Certified Professional Coder (CPC); Licensed or Certified healthcare profession; or Certified Fraud Examiner

• Techniques for investigating leads, gathering evidence, and interviewing parties

• Methods to detect, audit, and act upon fraud, waste, and abuse

• Coding systems (CPT, ICD-10, HCPCS)

• Health insurance benefits plans design and healthcare terminology

• Knowledge of detailed procedures used to bill and adjudicate healthcare claims, provider contracts, and regulatory requirements

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.