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Skills: Fraud Investigation, Healthcare Fraud Detection, Case Management, Data Analysis, Interviewing Skills
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$93k–$168k/yr
Full-time
bachelor degree, professional certificate, postgraduate degree
Health And Wellness Benefits, 401(k) Savings Plan, Pension Plan, Paid Time Off, Paid Parental Leave, Disability Insurance
Posted 27d ago
~40 hrs/week
Responsibilities
Manage healthcare and internal fraud investigations, specifically focusing on IL Medicaid, while supervising and training a team of investigators. Coordinate anti-fraud activities with law enforcement, legal departments, and other internal HCSC stakeholders.
Requirements
Requires a Bachelor's degree in Criminal Justice, Finance, or Accounting with 5 years of investigation experience and 1 year of leadership experience. Professional certifications such as AHFI, CPC, or CFE are required if the candidate lacks the specific degree/experience combination.
Full job description
At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.
Join HCSC and be part of a purpose-driven company that will invest in your professional development.
Job Summary
BASIC FUNCTION HCSC is looking for a dynamic individual to join its Fraud Investigations team! This position will be responsible for managing healthcare fraud and internal fraud investigations initially focusing on IL Medicaid; managing and training investigators as well as support staff; establishing and maintaining liaison with healthcare providers and law enforcement; and coordinating anti-fraud activities with other departments at HCSC. The role is hybrid flex and requires in-office visibility three days per week, working from home the other two days.
NOTE: relocation is NOT offered, sponsorship will NOT be extended either now or in the future.
JOB REQUIREMENTS:
Bachelor’s Degree in Criminal Justice, Finance or Accounting or related field and 5 years of direct law enforcement/investigation experience, including supervision of cases and investigators OR 9 years of direct professional work experience in the detection, investigation and/or prosecution of complex health care fraud schemes with the following professional certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), and/or Certified Fraud Examiner (CFE).
1 year of leadership or supervisory experience.
Strong organizational skills and results oriented with demonstrated leadership capabilities.
Keen analytical, interviewing, and investigative skills, with proficiency in data analysis and claims management systems.
Deep understanding of insurance fraud techniques, claims handling, and regulatory compliance.
Proficiency in anti-fraud analytics tools, case management software, and MS Office (Word, Excel, PowerPoint) as well as Workday.
PREFERRED JOB REQUIREMENTS:
Master’s Degree.
Experience with IL Medicaid FWA investigations.
~KEY FUNCTIONS ~
Develop and manage investigative group designed to detect, investigate, and refer health care fraud cases to law enforcement.
Ensure evidence collected, including documents and interview reports, are maintained in a manner to ensure integrity in court proceedings.
Ensure personnel are properly trained and managed in investigative techniques.
Prepare weekly investigative and activity reports.
Coordinate with other HCSC departments concerning ongoing anti-fraud programs and procedures.
Develop and maintain sources of information needed to detect health care fraud.
Develop and maintain liaison contacts with law enforcement.
Direct and supervise sensitive investigations when appropriate.
Deal directly with HCSC customers on fraud matters when appropriate.
Conduct monthly file reviews and provide direction to investigators regarding investigative strategies and plans.
Coordinate investigative activities with the Legal Department.
Ensure investigators are familiar and utilize health care fraud databases, including Fraud and Abuse Management System (FAMS).
Comply with federal and state reporting and fraud investigation requirements.
Communicate and interact effectively and professionally with co-workers, management, customers, etc.
Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
Maintain complete confidentiality of company business.
Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested
#LI-TP1
#LI-hybrid
Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!
Pay Transparency Statement:
At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.
The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.
HCSC Employment Statement:
We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.
Base Pay Range
$92,700.00 - $167,500.00
Exact compensation may vary based on skills, experience, and location.
Related keywords
Healthcare FraudIL MedicaidAHFICPCCFEFAMSHIPAAAnti-Fraud AnalyticsCase Management SoftwareInternal FraudLaw Enforcement LiaisonCriminal JusticeClaims HandlingRegulatory ComplianceWorkdayFraud And Abuse Management System
Empowering Member Health With Compassion and Innovation
Industry
Hospitals and Health Care
Company size
10,001+ employees
Headquarters
Chicago, IL
LinkedIn followers
166,193
Health Care Service Corporation serves nearly 23 million people across the United States through its portfolio of health benefit solutions.
HCSC provides health coverage options for employers large and small, individuals and families, and Medicare and Medicaid plans. HCSC also offers related health care products and services such as pharmacy solutions, life and dental insurance, and health data technology. A Mutual Legal Reserve Company, HCSC is an independent licensee of the Blue Cross Blue Shield Association.
For nearly a century, we have enabled and coordinated the access to quality care for millions of members. Our experience and industry knowledge establishes a solid foundation for our future—driving innovations that further expand access, improve health outcomes, and reduce costs.
Embedded within the fabric of how we operate is a deep sense of caring and commitment that informs how we serve our members, engage in local communities, and deliver positive change to the health care industry.
As health care needs evolve, we leverage our portfolio of companies to deliver differentiated value to all industry stakeholders so that, together, we make more possible.
Join HCSC and discover what new ways of thinking can mean for you, your community, our customers and our organization: HCSC.com/careers. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to an inclusive, drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability, or protected veteran status.
Image(s) may have been created or enhanced using artificial intelligence tools.
Offices: 300 E Randolph St, Chicago, IL 60601, US · 5701 Balloon Fiesta Pkwy NE, Albuquerque, NM 87113, US · 1215 S. Boulder, Tulsa, OK 74119, US · 1001 East Lookout Drive, Richardson, TX 75082, US · 560 N. Park Ave, PO Box 4309, Helena, Montana 59604, US
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