SCOPE OF ROLE

Under the direction of the SIU Manager, the Senior Analyst, Special Investigations Unit (SIU) will work to prevent, detect and investigate known or suspected acts of fraud. The Senior Analyst will be responsible for coordinating investigation activities, conducting comprehensive investigations of reported, alleged, or suspected fraud involving the full range of products at Bright Health, and contributing to the development and administration of Fraud, Waste, and Abuse (FWA) analytical tools.

ROLE RESPONSIBILITIES

The Senior Analyst, Special Investigations Unit job description is intended to point out major responsibilities within the role, but it is not limited to these items:

• Perform Data Mining Activities
• Performs investigation of credible instances of suspected fraud, and coordinates communication with all parties involved
• Prepare reporting for internal analysis and external reporting requirements
• Support the development of tools, templates, and strategies to proactively analyze data and identify potential FWA trends
• Establish and maintain liaison with public officials, law enforcement and others to obtain assistance in conducting investigations
• Fulfill response requests for Requests for Information (RFI) and other external requests from state and federal regulators, attorneys, and other entities as necessary

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree or equivalent experience required.
• At least 2 years of experience performing SIU investigations at a healthcare company. 3-5 years of experience preferred.
• Health insurance experience.

PREFERRED COMPETENCIES

• Bilingual Spanish and English speaking, and/or
• Clinical training, and/or
• Certified coder or deep subject matter expertise regarding coding, and/or
• Experience analyzing data and identifying patterns
• At least one of the following: Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Anti-Money Laundering and Fraud Professional (CAFP), Certified Professional Coder (CPC) or similar certification/credential.

BEHAVIORAL AND LEADERSHIP NORMS

• Bright Values: Lives the Bright Values.  Is focused on bravery needed to develop a variety of skills. Not afraid to ask questions or take risks. Focuses on purposeful planning and objective setting. Focuses on the team’s successes, and how to support that effort.
• Collaboration:  Is an effective collaborator that works well with the functional team and others in the organization to align on timelines and effective delivery of a project or task. Is solution oriented and works on generating input from multiple constituents and driving the team to a solution. Is able to work with different personality types and teammates to overcome differences in opinion and thought to achieve common company goals.
• Delivers Results: Is results oriented. Focuses on results and the best and most efficient avenue for achieving results. Works with manager or appropriate liaison in the organization to work through goal setting and milestone development to ensure timely and high-quality work product. Achieves strong results within functional area. Is focused on managing against a predetermined set of objectives and creates and follows process. Delivers outstanding and sustained results.
• Exhibits Curiosity: Focuses on learning about the business at large. Seeks to understand how they can drive the business forward and how the bigger picture works. Actively participates in his/her own career development.

• Multi-tasking:  Balances multiple projects and initiatives at any given time. Alongside manager or appropriate Bright teammate, re-evaluates priorities based on changing company needs to understand what must be done today. Able to balance multiple projects and initiatives at any given time. Capable of deciphering which priorities are most important for the function/organization. Consistently meets deadlines.
• Training and Mentoring: Helps train and mentor others: Actively participates in the onboarding and ongoing success of teammates. Onboards, trains and provides informal mentorship to new and existing teammates (interns, consultants, etc.). Provides thoughtful solutions, direction and advice to others, and help advise on priorities.
• Upward Management: While balancing multiple initiatives, successfully manages expectations with appropriate project owner about capacity, challenges and barriers to success. Is not afraid to ask for help, guidance or feedback.

LICENSURES AND CERTIFICATIONS

• See “Education, Training, and Professional Experience”

WORK ENVIRONMENT

This job is a remote / flexible role and will not require in-office presence.