Manage, organize, plan and control all field activities related to the investigation, prevention and prosecution of unlawful activities directed against Blue Cross Blue Shield of Michigans (BCBSM) assets and the recovery of assets lost as a result of those unlawful activities.
Manage Field Investigators, plan and assign work, review performance, conduct training, prepare management reports and complete administrative tasks as assigned.
Conduct detailed and accurate investigations of all cases assigned throughout the State of Michigan and nationally to include violations of the code of conduct and compliance policy.
Investigate facts necessary to support decisions to pursue administrative, criminal, civil or recovery action based on fraud, abuse or criminal action and ensure steps to recover improper payments.
Prepare detailed reports of all investigative findings and present as evidence to BCBSM staff for review and/or law enforcement officials for successful prosecution of fraudulent activities.
Present detailed and accurate testimony to federal, state and local courts as well as other state hearings and those hearings required by the master labor agreement.
Maintain primary liaison with major BCBSM customers and federal, state and local law enforcement agencies for the purpose of attaining investigative objectives.
Responsible for the prevention and deterrence of fraudulent activities involving the loss of BCBSM assets and maintain the integrity of BCBSM claims and benefit payment systems.
Review and provide input on proposed and pending legislation affecting the health care industry.
Report issues of improper or inadequate policies and procedures of all BCBSM systems detected during the conducting of investigations for collaboration with to the audit areas of the corporation.
Bachelor's Degree in Criminal Justice, Business Administration or related field is required.
Seven (7) years of experience investigating financial fraud, internal affairs, organized crime, white-collar crime or complex investigations working directly with federal, state or local law enforcement agencies is required.
Three (3) years of experience leading a team is preferred.
Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC) certification(s) is preferred.
Excellent analytical, organizational, planning, problem solving, verbal and written communication skills.
Ability to maintain composure and confidence in risk situations and work under minimal direction.
Comprehensive knowledge of legal and investigative procedures used in the detection and successful prosecution of health care fraud cases.
Advanced knowledge of witness and suspect interviews, evidence gathering, surveillance, undercover activity and investigative report writing as well as criminal law and procedures.
Advanced understanding of federal and state judicial processes related to fraud prosecutions.
Advanced understanding of accounting procedures and proactive data processing systems.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity
Please see job description for required skills.