Capital BlueCross
Clinical Special Investigator (Administrative)
The Clinical Special Investigator is responsible for identifying and investigating suspected cases of claim and program fraud waste or abuse. The Clinical Special Investigator is responsible for proactive review of claims reports and the anti-fraud software reports for the purpose of identifying and initiating an investigation The Clinical Special Investigator will apply clinical standards, medical policies and coding guidelines when reviewing medical records and claims data to identify areas of potential overpayments.
Furthermore, the Clinical Special Investigator will work with the medical director to provide a clinical/coding summary and to complete cases based on the findings. Throughout the process the clinical special investigator is expected to maintain detailed documentation including interview notes, investigative steps and summaries and case outcomes.
The Clinical Special Investigator will be able to communicate effectively in writing and orally case findings, coding guidelines and be able to explain all aspects of the case as needed internally, externally with providers, law enforcement or other professional organizations.
The Clinical Special Investigator will actively participate in the development and annual review of policies, procedures, and desktops.
Identify and investigate cases of suspected fraud waste or abuse to include:
Participate in cross-department workgroups and committees
Participate in development and review of SIU Policies/Procedures and Desktops
JOB REQUIREMENTS
Knowledge:
Work Environment:
Physical Demands:
Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.