Senior Investigator

Fargo, ND
Join our team!
Mar 08, 2018
Job Type
Full Time
The Senior Investigator is responsible for independently investigating allegations of fraud, waste and abuse by healthcare providers, facilities, members, and/or groups and proactively identifies areas of concern using claim data analysis, tips, interviews and other means. This position will initiate, develop, complete and resolve investigations of mid- to high- level complexity, supports unit manager by reviewing case files, training Special Investigations Unit (SIU) staff and developing and providing fraud, waste and abuse awareness training to internal departments and external contacts.

Essential Functions

  • Uses software analysis and other resources to conduct investigations and proactively identify aberrant patterns and/or suspected fraud, waste or abuse practices. Interprets and analyzes complex data and identifies and eliminates false positive data.
  • Assesses the company's potential exposure level (current and future) to help determine case prioritization.
  • Determines the most effective and efficient method of investigation for each case, gathers and analyzes data from internal and external resources and documents all steps of investigations.
  • Collects and preserves evidence in a manner that protects its integrity in the event of prosecution.
  • Performs investigative field work such as interviews, onsite audits, surveillance and undercover operations.
  • Develops detailed formal case reports and corrective action plans as appropriate for each investigation.
  • Manages a full case load by performing multiple investigations concurrently and provides case oversite to ensure thorough case development and resolution.
  • Resolves cases by submitting claims for adjustment in accordance with established processes.
  • Collaborates with management to determine case adjudication and partners with multiple departments in the company, other Blue Plans, FBI and others such as the main SIU contact on multi-jurisdictional cases.
  • Provides training to new team members, internal departments, external contacts.
  • Submits any recommendations for internal process improvement to prevent future fraud, waste, or abuse occurrences to management team.


Knowledge, Skills and Abilities

Attention to Detail and Accuracy


Effective Interpersonal Communications


Ethics and Integrity


Research and Data Analysis


Analytical Thinking


Initiative and Creativity


Education Requirements

Required: Bachelor's

Preferred: Bachelor's

Field(s) of Study: Healthcare, business, finance, criminal justice, or related field

Experience Requirements

Required: Minimum of 5 Years

Preferred: Minimum of 7 Years

Experience Details: Minimum of 5 years of audits, data analysis, investigations, law or related experience is required; experience with structured analysis or investigation is required.

Certification, Licensures & Registration Requirements

Title: Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC) or equivalent is required.

Other Information

Job Posting Policy 6.05

New employees with Blue Cross Blue Shield of North Dakota will be eligible to apply for positions within their assigned department after successfully completing a 90-day review. For positions outside your department, you must attain a minimum of six months of service before you can apply.

Equal Opportunity Employment

Equal Opportunity Employer of Minorities, Females, Protected Veterans and Individual with Disabilities, as well as Sexual Orientation or Gender Identity.

For questions, please email

This job posting will be closed 4/6/2018 at 8:00AM CST. No further applications will be considered.

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