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Independence Blue Cross · 17 hours ago

Investigative Support Specialist

Philadelphia, Pennsylvania

Full-time

Hybrid

Mid Level

3+ years exp

Independence Blue Cross is seeking an Investigative Support Specialist to join their Corporate and Financial Investigations Department. This role involves safeguarding the integrity of Independence affiliates by investigating allegations of fraud, waste, and abuse in medical and pharmacy utilization, as well as performing proactive data analysis.

Health CareHealth InsuranceInsuranceMedical

Responsibilities

Research and resolve FWA allegations by reviewing claims and medical records for compliance with plan guidelines

Initiate claim retractions or corrections for billing/coding errors; escalate suspected fraud to Investigations

Handle Medicare-related allegations and report outcomes to MAG for subscriber notifications

Independently decide on claim adjustments, repayments, and referrals

Collaborate with senior analysts on proactive reviews, trend analysis, and provider audits

Utilize tools (Informant, Fraud Shield, INSINQ) to monitor claims, flag members, and analyze provider patterns

Manage recovery processes for overpayments and ensure accurate financial reporting

Monitor flagged accounts for potentially fraudulent activity for 90 days

Qualification

Fraud Analysis CertificationClaims Payment SystemBenefit AnalysisMedical Policy KnowledgeProvider Contracts KnowledgeProblem SolvingIndependent WorkTeam Collaboration

Required

3-5 years of relevant experience

High School degree or equivalent

Has in-depth knowledge in own discipline and extensive knowledge of related disciplines such as claims payment system, benefit analysis, medical policy, and provider contracts

Based on analysis and research, initiates claim offsets, retractions, and demand letters for provider repayment agreements

Solves complex problems; takes a new perspective on existing solutions such as claims payment edit updates, medical policy change, and provider contract/third party issues

Works independently; receives minimal to no guidance. Acts as a resource for colleagues with less experience and peers

Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app