Investigator III

Overview

Workforce Classification:

Hybrid

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As a member of Premera’s Special Investigations Unit (SIU), the Investigator III leads complex investigations into allegations of external fraud, waste, and abuse (FWA). This role manages medium to high complexity cases from initiation through resolution, producing thorough, well documented investigative reports that may be subject to legal discovery. The Investigator III conducts detailed analysis, collaborates closely with SIU colleagues, and balances multiple investigations simultaneously.

In this role, you will also work to identify and recover improper payments resulting from fraudulent or misrepresentative billing, while ensuring all investigative activities comply with company policies, regulatory requirements, and applicable laws. As a not-for-profit organization, Premera offers the opportunity to do this work with a genuine focus on doing what’s right for our members—supported by leaders who believe in the impact this team makes, not just the metrics.

What you’ll do:

• Analyze healthcare claim data and vet referrals to detect fraudulent activity and independently determine the most effective and efficient method of investigation for each individual case.

• Perform investigative field work to include on-site office visits, record collection, and surveillance.

• Interview suspects and witnesses.

• Prepare cases, testify and give depositions to law enforcement and regulatory agencies for potential criminal prosecution.

• Participate in settlement negotiations with attorneys and other responsible parties.

• Perform root cause analysis of identified issues and prepare post-investigative reports directed towards the prevention of fraud.

• Make recommendations for creating SIU policies, procedures, workflows and process improvements.

• Develop and maintain collaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA), Blue Cross Blue Shield (BCBS) Plans, HHS OIG, other carriers’ anti-fraud professionals, law enforcement and regulatory agencies.

• May attend webinars and conferences like BCBSA, National Health Care Anti-Fraud Association (NHCAA), and Association of Certified Fraud Examiners (ACFE) to keep apprised of developments in health care fraud.

What you’ll bring:

• Bachelor’s degree in business administration, health care administration, finance, accounting, nursing or criminal justice or (4) years of work experience in field of study. (Required)

• (3) years of experience in fraud investigation, special investigation unit, or a related field. (Required)

• Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI).

• Two (2) years of active experience in auditing and investigating in the healthcare industry.

• Significant experience with relevant technology, such as background check systems, claims processing platforms, data mining, and fraud detection software.

• Demonstrated knowledge of institutional and/or professional payment methodologies.

• Strong understanding of health insurance reimbursement methodologies, including familiarity with ICD-10 CM, CPT, and HCPCS.

• Strong computer aptitude and experience with spreadsheet and database software, e.g., Excel, Access, Focus.

• Demonstrated strong technical writing skills – ability to write reports and business correspondence and to prepare case files.

• Abili…