Overview
Consultant FEP SIU Jobs in Washington – District of Columbia – USA at Blue Cross Blue Shield Association
Title: Consultant FEP SIU
Company: Blue Cross Blue Shield Association
Location: Washington – District of Columbia – USA
Type: Full Time
Category: Security
Job Description Summary
Executes measures for theprevention, identification and investigation of fraud, waste, and abuse (FWA) perpetrated against the Federal Employee Program (FEP). Ensures that Blue Cross Blue Shield (BCBS) Plans and Pharmacy Benefit Managers (PBMs) meet reporting requirements as mandated by the Carrier Letter and FEP Special Investigations Unit (FEP SIU) Standards Manual.
Provides Plan and PBM oversight for the identification, investigation, and reporting of FWA. Coordinates and facilitates single and multi-Plan investigative efforts. Conducts training as required.
Participates in special projects as required. Conducts research relating to FWA and participates in the training of vendors and Plans.
Assists internal/external entities with various types of litigation support.
Supports various FEP SIU systems. Interacts with various areas of BCBSA regarding issues identified through investigations and reviews.
Provides Plan/PBM oversight for the identification and investigation of non-compliance issues.
Monitors and ensures Plan/PBM compliance with internal systems and programs. Coordinates and facilitates single and multi-Plan/PBM investigative efforts.
Develops and participates in special projects as required.
Lead or support various Anti-Fraud projects through the year as determined by the business.
Job Description
Provides FWA program oversight to enhance BCBS FEP investigations and training opportunities related to OPM OIG Carrier Letter reporting requirements, FEP SIU Tracking System (FSTS) compliance, and other internal systems and program requirements.
Coordinates and facilitates single and multi-Plan/PBM investigative efforts. Presents documentation and other factual material for referral to OPM-OIG and other local, state, federal law enforcement and prosecutorial agencies.
Supports Plan/PBM SIUs and OPM-OIG in working FEP health care FWA investigations. Leads proactive special projects in support of FEP SIU and organizational goals to include identifying health care fraud schemes and trends.
Responsible for working with and advising BCBS Plans/PBMs. Develops, facilitates, and delivers compliance training regarding FEP contract performance, as well as expectations of OPM and OPM-OIG.
Maintains and cultivates good working relationships with various local, state, and federal agencies by attending task force meetings, participating in working groups. Delivers presentations to various stakeholders.
Provides program improvement recommendations in the area of fraud detection and investigation services in support of the Federal Employee Program (FEP) Anti-Fraud Programs.
Analyzes FEP claims data to develop health care fraud investigations for referral to various parties including federal, state and local authorities, Blue Plan anti-fraud units and internal and external FEP departments.
Responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities committed against FEP by health care providers/facilities/members and others.
Provides recommendations for program edits and policy changes to mitigate FWA.
Education
Bachelors Degree
Bachelor’s degree in criminal justice, healthcare, intelligence, business, compliance or related discipline or equivalent experience is required.
Certifications
Certification as an Accredited Health Care Fraud Investigator or a Certifi…