Program Integrity Analyst​/Investigator Clinical - Behavioral Health

Program Integrity Analyst / Investigator Clinical – Behavioral Health is a hybrid role located in Eagan, Minnesota. Blue Cross and Blue Shield of Minnesota is an Equal Opportunity Employer and maintains an affirmative action plan as required by Minnesota law. All qualified applications will receive consideration for employment without regard to legally protected characteristics.

Blue Cross and Blue Shield of Minnesota is committed to paving the way for everyone to achieve their healthiest life. The organization values succeeding together, finding better ways, and doing the right thing. Join us and make a difference.

The Program Integrity Analyst / Investigator Clinical – Behavioral Health is responsible for the prospective and retrospective investigation of suspect claims and the development of fraud, waste, abuse and over-payment recovery cases. The role involves gathering, analyzing and interpreting complex data to develop leads, collaborating with internal resources, and complying with state and federal fraud, waste and abuse detection and prevention requirements.

• Analyze and triage referrals/leads to determine appropriate research and investigation needed with minimal guidance.
• Conduct interviews of patients, providers, provider staff and other witness/experts.
• Utilize clinical expertise, health plan knowledge, and claims analysis to review and assess medical records for appropriateness.
• Represent Blue Cross by testifying at trials, offering depositions and responding to subpoenas.
• Prepare for and facilitate settlement negotiations with providers, attorneys and other responsible parties with minimal supervision.
• Document case activity, fund allocation and conduct follow-up actions in a timely manner following documented departmental guidelines.
• Refer well documented and substantiated cases to law enforcement agencies such as the FBI, OIG and local police departments.
• Meet all contractual, state and federal regulations and reporting requirements as established by CMS, FEP/OPM, DHS and other agencies.

• Registered nurse or licensed behavioral health clinician (e.g., LICSW, LPCC, LMFT, LP, LADC, LBS, BCBA) with current MN license and no restrictions or pending restrictions.
• 3+ years of related professional clinical experience.
• 4 years of fraud, waste and abuse investigation/loss prevention experience and experience using data analysis tools (e.g., Healthcare Fraud Shield).
• Excellent written and oral communication skills, including the ability to communicate with management, regulators and law enforcement.
• Proven analytic, writing and reasoning skills to evaluate complaints, referrals, health care data and relevant federal laws and regulations.
• Strong organizational skills and the ability to manage and prioritize multiple investigations, projects and responsibilities.
• Ability to work independently with excellent attention to detail.
• Proficient use of Microsoft Word, Excel, PowerPoint and Visio.
• Accredited Health Insurance Fraud Investigator (AHFI) in good standing through NHCAA within five years of hire.
• Ability to travel during the workday and potential overnight travel.
• Valid driver’s license and auto insurance or access to reliable transportation.
• High school diploma or equivalency and legal authorization to work in the U.S.

• Bachelor’s degree.

Pay Range: $68,900.00 – $91,300.00 – $ Annual.

Benefits may include: medical, dental and vision insurance; life insurance; 401(k); paid time off (PTO); volunteer paid time off (VPTO); and more.

Individuals with a disability who need a reasonable accommodation in order to apply, please contact us at: talen