Investigative Support Specialist
Bring your drive for excellence, team orientation, and customer commitment to Independence; help us renew and reimagine our business and shape the future of health care. Our organization is looking to diversify, grow, innovate, and serve, and we are seeking an Investigative Support Specialist
Independence’s Corporate and Financial Investigations Department (CFID) safeguards the integrity and assets of Independence affiliates and customers by identifying, preventing, and reporting potential fraud, waste, and abuse (FWA) in medical and pharmacy utilization, as required by regulators, including CMS.
The CFID Support Team investigates allegations of FWA, which may involve requesting medical records, retracting claims, seeking repayments, or referring cases to the Investigative Unit. The team also performs proactive data analysis to identify entities for audit or investigation.
Key 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.
QUALIFICATIONS:
3-5 years of relevant experience.
High School degree or equivalent.
Working toward a Certification in Fraud Analysis is preferred.
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
Independence has implemented a “Hybrid” model which consists of Associates working in the office 3 days a week (Tuesday, Wednesday & Thursday) and remotely 2 days a week (Monday & Friday). This role is designated as a role that fits into the “Hybrid” model. While associates may work remotely on our designated remote days, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
Inclusion and Belonging
At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an Independence Blue Cross employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.