Investigator – Health Insurance
| Company | Wellmark |
|---|---|
| Location | Cedar Rapids, IA, USA |
| Salary | $Not Provided – $Not Provided |
| Type | Full-Time |
| Degrees | Associate’s |
| Experience Level | Junior, Mid Level |
Requirements
- Associate degree in related field or direct and applicable work experience.
- 1+ year of experience in Health Insurance operations including applicable rules/regulations, or related experience.
- Ability to follow procedures for identifying, reporting and preventing fraud, waste and abuse.
- Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes.
- Demonstrated analytical skills to recognize inconsistencies, research, obtain information from multiple sources and come to a conclusion.
- Ability and willingness to approach complex problems from different angles and produce creative, innovative solutions while ensuring compliance with laws and internal procedures.
- Skilled at researching and using appropriate interaction skills and methods to come to conclusions.
- Strong verbal and written communication skills with the ability to articulate complex information clearly and concisely while maintaining courtesy and professionalism to a variety of stakeholders, both internally and externally.
- Ability to work with others in difficult and complex situations to achieve resolution or adherence to laws and/or regulations.
- Ability to organize and manage multiple conflicting priorities in a dynamic work environment. Prior experience using Microsoft Office applications such as Word, Excel and/or Outlook and the ability to learn new systems quickly.
- Travel required up to 5%
Responsibilities
- Identify and investigate suspected provider and member health insurance fraud, waste and abuse.
- Identify potential losses and recoveries for the corporation.
- Prepare reports of suspected fraud, waste and abuse.
- Work with law enforcement agencies and anti-fraud organizations, as appropriate.
- Conduct investigations in accordance with company policies and procedures and in compliance with all applicable laws and regulations.
Preferred Qualifications
- Experience in fraud, waste and abuse investigations.
- Experience in facilitating presentations/trainings.
- Ability to navigate and thrive in ambiguous situations, effectively adapting to changing priorities and making informed decisions with limited information.