Medical Practice Investigation Specialist at Blue Cross Blue Shield Kansas in Topeka, Kansas

Job Description:

Under limited supervision, the medical practice investigations specialist will play a critical role in detecting and preventing healthcare waste and abuse to optimize network integrity. The investigator will utilize various investigative techniques to manage and conduct activities related to capture, analysis, and correlation of substantial amounts of claims data to identify anomalous medical practice patterns that result in significant fiscal impact to the company and/or healthcare impact to the member.


"Upon completion of the initial six-month training period, this position will be eligible for hybrid work. After the training is completed, employees may choose to work onsite or in a hybrid capacity (a minimum of 9 days per month onsite), in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment."



Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.




Why Join Us

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  Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
  
  


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  Professional Growth Opportunities: Advance your career with ongoing training and development programs.
  
  


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  Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.
  
  


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  Trust: Work for one of the most trusted companies in Kansas
  
  


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  Flexibility: options to work onsite or hybrid available
  
  


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  Inclusive Work Environment: We pride ourselves on fostering a diverse and inclusive workplace where everyone is valued and respected.
  
  

Compensation



$30.11 - $35.80 hourly
Non-Exempt 14

• Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.
  
  
  

What you'll do

• Performs investigations into potential and existing providers which includes reviewing claims data, medical reviews, provider files, etc. and utilizing data analysis techniques to detect irregularities, billing trends, and financial relationships in BCBSKS claims data to detect potential wasteful or abusive billing practices or vulnerabilities in the BCBSKS provider network. Conducts telephone and/or in person interviews with members and/or providers and/or provider staff to determine the validity of claims filed in the furtherance of an investigation or case.
  
  


• Utilize and validate data analysis results and analytically identify potential waste and/or abuse situations in violation of Medicare/Medicaid laws, guidelines, policies, and regulations. This includes proactively seeking out and developing leads/cases from a variety of sources including CMS and OIG, internal alerts, and referrals from external parties.
  
  


• Analyze information gathered during the investigation for potential patterns of anomalous medical practice and prepare a detailed written summary of findings and recommendations for potential corrective action. Validation and analysis of data requires extensive use of industry standard code sets (ICD10, CPT, HCPCS etc.). This information is presented to senior management, as necessary.
  
  


• Identifies and investigates anomalous medical practice patterns or inappropriate utilization by conducting pre-payment reviews and post payment audits of claim activity by providers as needed. To include requesting and reviewing medical records.
  
  


• Collaborates with departments and all levels of staff through the organization to foster a partnering-based approach to investigations and anomalous medical practice pattern identification activities with sub-contractors, vendors, and other covered entities. This includes engaging other risk management functions and/or forwarding cases as needed to internal committee teams.
  
  


• Assists in the development of new methods, processes, and programs to analyze and report medical practice information. Recommend changes to medical policy, provider manuals, policy memos, and provider workshops. Assists in maintaining departmental processes and procedures.
  
  


• Assists in providing education to providers on proper billing and documentation requirements.
  
  


• Respond to requests for information from provider licensing board, State Insurance Departments, and law enforcement agencies.
  
  


• Collaborate with legal and other regulatory agencies as needed for testimony, workpaper review, investigation discussions, etc. Testify in civil proceedings as needed.
  
  

What you need



Knowledge/Skills/Abilities

• Knowledge of ICD10, HCPCS and CPT coding systems preferred.
  
  


• Demonstrated ability to use data analysis and extraction tools, such as Excel to assess transactions and identify potential billing discrepancies or errors.
  
  


• Ability to work independently with minimal supervision, excellent reliability and demonstrated ability to work timely and effectively under strict guidelines.
  
  


• Self-directed with the ability to make independent decisions and prioritize work related tasks.
  
  


• Excellent interpersonal skills with the ability to establish working relationships inside and outside of the organization.
  
  


• Must demonstrate good judgement and attention to detail along with strong critical thinking and problem-solving skills.
  
  


• Maintain confidentiality of all sensitive information and secure PHI as required by law and regulations.
  
  


• Must comply with and implement corporate information security policies, standards, and guidelines relative to access control.
  
  


• Must support and exhibit the company's values of integrity, dependability, service, growth and progress, and courage.
  
  

Education and Experience

• High school diploma or equivalent required.
  
  


• Bachelor of Science preferred. In lieu of a degree, a minimum of 3 years' experience in related field required.
  
  


• Certified Professional Coder (CPC) required within 1 year of hire and must be maintained with CEU's as needed.
  
  


• Experience in a medical or healthcare role, such as medical assistant, certified nursing aide, or medical records specialist preferred.
  
  
  

Physical Requirements

• This position is approximately 90% PC work and 10% phone calls.
  
  


• The position is onsite in Topeka with the potential to work hybrid after training is complete.
  
  

Benefits & Perks

• Base pay is only one component of your competitive Total Rewards package
  
  


• Incentive pay program (EPIP)
  
  


• Health/Vision/Dental insurance
  
  


• 6 weeks paid parental leave for new mothers and fathers
  
  


• Fertility/Adoption assistance
  
  


• 2 weeks paid caregiver leave
  
  


• 5% 401(k) plan matching
  
  


• Tuition reimbursement
  
  


• Health & fitness benefits, discounts and resources
  
  

Our Commitment to Diversity, Equity, Inclusion, and Belonging



At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of diversity, equity, inclusion, and belonging (DEIB), where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law.


We believe that embracing diversity and authentically promoting inclusion, equity, and belonging among our team members is crucial to our collective success. By intentionally recruiting, developing, and retaining a diverse pool of talent, we cultivate an environment where everyone feels valued, heard, and empowered to contribute. Accommodations are available for applicants with disabilities upon request, ensuring an inclusive and accessible hiring process for all. Apply Now