Investigator II

BlueCross BlueShield of Tennessee

Job Overview

Location

USA, TN, Nashville, Remote

Job Type

Full-time

Full Job Description

📋 Description

• Lead end-to-end fraud investigations focused on healthcare fraud and white-collar criminal activity to protect members and organizational resources.
• Analyze evidence, identify patterns of fraudulent behavior, and conduct ongoing investigations to determine the validity of claims.
• Conduct interviews with claimants, providers, and other parties involved to gather critical information for case evaluation.
• Prepare comprehensive legal and investigation documentation, including case files, reports, and recommendations for management.
• Present findings and recommendations to leadership to support decision-making and enhance fraud prevention strategies.
• Participate in legal proceedings as needed, providing expert testimony and supporting litigation efforts.
• Evaluate each case for financial risk, compliance impact, and potential for systemic fraud trends to strengthen internal controls.
• Serve as a trusted advisor by delivering data-driven insights that inform organizational policy and improve fraud detection protocols.
• Utilize Microsoft Office Suite (Outlook, Word, Excel, PowerPoint) to document findings, manage case files, and communicate results.
• Work independently with minimal supervision while maintaining accountability and meeting strict deadlines.
• Collaborate effectively within a team environment, sharing responsibilities and contributing to collective investigative goals.
• Travel occasionally across Tennessee for provider site visits and periodic work at the Chattanooga office.
• Adhere to the BCBST Driver Safety Program if required to operate a personal, rental, or company vehicle for business purposes, including maintaining a valid driver’s license, auto insurance, and an acceptable motor vehicle record.
• Employ responsible use of AI-enabled tools to enhance investigation efficiency and member service outcomes.
• Maintain strict confidentiality and integrity in handling sensitive member and claims data.
• Ensure all investigations comply with applicable laws, regulations, and internal compliance standards.
• Contribute to continuous improvement of fraud prevention strategies through trend analysis and proactive recommendations.

🎯 Requirements

• 8 years of experience in healthcare fraud investigations or similar white-collar criminal investigations
• Bachelor's Degree or equivalent work experience (4 years of professional corporate experience)
• Industry certification such as CFE, AHFI, ALHC, or CIFI
• Proficiency in Microsoft Office (Outlook, Word, Excel, PowerPoint)
• Excellent oral and written communication skills
• Ability to work independently with minimal supervision and manage multiple projects simultaneously

🏖️ Benefits

• Remote work arrangement with occasional travel across Tennessee
• Opportunity to work with AI-enabled tools to enhance investigative efficiency
• Collaborative team environment with direct impact on member protection and organizational integrity
• Adherence to BCBST’s equal employment opportunity policies and inclusive workplace culture

Skills & Technologies

Remote

Degree Required

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BlueCross BlueShield of Tennessee

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About BlueCross BlueShield of Tennessee

BlueCross BlueShield of Tennessee is the largest health-benefit plan company headquartered in the state, providing medical, dental, vision, and Medicare Advantage coverage to individuals, employers, and government programs. Founded in 1945 as a nonprofit mutual insurance company, it administers benefits for more than 3 million members through statewide provider networks, care-management programs, and digital health services. The company also engages in community health initiatives, preventive-care outreach, and value-based reimbursement models to improve outcomes and manage costs across Tennessee.

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