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Job Summary

BASIC FUNCTION HCSC is looking for a dynamic individual to join its Fraud Investigations team! This position will be responsible for managing healthcare fraud and internal fraud investigations initially focusing on IL Medicaid; managing and training investigators as well as support staff; establishing and maintaining liaison with healthcare providers and law enforcement; and coordinating anti-fraud activities with other departments at HCSC. The role is hybrid flex and requires in-office visibility three days per week, working from home the other two days. NOTE: relocation is NOT offered, sponsorship will NOT be extended either now or in the future. JOB REQUIREMENTS: Bachelor’s Degree in Criminal Justice, Finance or Accounting or related field and 5 years of direct law enforcement/investigation experience, including supervision of cases and investigators OR 9 years of direct professional work experience in the detection, investigation and/or prosecution of complex health care fraud schemes with the following professional certifications: Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), and/or Certified Fraud Examiner (CFE). 1 year of leadership or supervisory experience. Strong organizational skills and results oriented with demonstrated leadership capabilities. Keen analytical, interviewing, and investigative skills, with proficiency in data analysis and claims management systems. Deep understanding of insurance fraud techniques, claims handling, and regulatory compliance. Proficiency in anti-fraud analytics tools, case management software, and MS Office (Word, Excel, PowerPoint) as well as Workday. PREFERRED JOB REQUIREMENTS: Master’s Degree.

Experience

with IL Medicaid FWA investigations. ~KEY FUNCTIONS ~ Develop and manage investigative group designed to detect, investigate, and refer health care fraud cases to law enforcement. Ensure evidence collected, including documents and interview reports, are maintained in a manner to ensure integrity in court proceedings. Ensure personnel are properly trained and managed in investigative techniques. Prepare weekly investigative and activity reports. Coordinate with other HCSC departments concerning ongoing anti-fraud programs and procedures. Develop and maintain sources of information needed to detect health care fraud. Develop and maintain liaison contacts with law enforcement. Direct and supervise sensitive investigations when appropriate. Deal directly with HCSC customers on fraud matters when appropriate. Conduct monthly file reviews and provide direction to investigators regarding investigative strategies and plans. Coordinate investigative activities with the Legal Department. Ensure investigators are familiar and utilize health care fraud databases, including Fraud and Abuse Management System (FAMS). Comply with federal and state reporting and fraud investigation requirements. Communicate and interact effectively and professionally with co-workers, management, customers, etc. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. Maintain complete confidentiality of company business. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested #LI-TP1 #LI-hybrid Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! Pay Transparency Statement: At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. HCSC Employment Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Base

Pay Range

$92,700.00 - $167,500.00 Exact compensation may vary based on skills, experience, and location. Join our talent community and receive the latest HCSC news, content, and be first in line for new job opportunities. Join our Talent Community. For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities. Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren’t afraid to make innovative contributions. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Learn more about HCSC, our commitment to our members and the opportunity you’ll have to improve health care delivery in an open, collaborative environment. HCSC is committed to diversity in the workplace and to providing equal opportunity to employees and applicants. If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations. Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "candidate home" to view your job submissions. Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas, Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, and Independent Licensee of the Blue Cross and Blue Shield Association © Copyright 2025 Health Care Service Corporation. All Rights Reserved.