Columbus - BWC Fraud Analyst (Healthcare Fraud Investigative Specialist) PN: 20066775

What our employees have to say:

BWC conducts an internal engagement survey on an annual basis. Some comments from our employees include:

• BWC has been a great place to work as it has provided opportunities for growth that were lacking in my previous place of work.
• I have worked at several state agencies and BWC is the best place to work.
• Best place to work in the state and with a sense of family and support.
• I love the work culture, helpfulness, and acceptance I've been embraced with at BWC.
• I continue to be impressed with the career longevity of our employees, their level of dedication to service, pride in their work, and vast experience. It really speaks to our mission and why people join BWC and then retire from BWC.

If you are interested in helping BWC grow, please click this link to read more, and then come back to this job posting to submit your application!

What You'll Be Doing:

• Acts as primary lead in the investigation of complex health care fraud cases.
• Independently receives, analyzes & responds to a caseload of complex allegations of Workers' Compensation Fraud (e.g. complex health care fraud schemes, conspiracy cases, multijurisdictional cases).
• Acts as a lead worker (i.e. provides work direction) over staff who may assist with assigned HCF investigations and assists &/or conducts joint investigations with local, state & federal law enforcement agencies (e.g., Health & Human Services; Federal Bureau of Investigation; Internal Revenue Service; Postal Inspection).
• Acts as a lead worker over new hires as a Field Training Officer (FTO).
• Serves as LEADS TAC (when needed).
• Acts as an evidence technician.
• Leads the administrative and technical aspects of the health care fraud undercover operations.
• Takes responsibility for records & information management (RIM) policies & procedures.
• Works closely with HCPT Management in reviewing investigative data trends impacting the success of health care fraud investigations.

54 mos. exp. in private insurance organization as claims representative, criminal investigator, rehabilitation case manager or equivalent position; 6 mos. exp. in operation of personal computer; valid driver's license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.

• Or completion of undergraduate core coursework in business, criminal justice, humanities, social & behavioral science, education or related field; 18 mos. exp. in insurance organization as claims representative, criminal investigator, rehabilitation case manager or equivalent position; 6 mos. exp. in operation of personal computer; valid driver's license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment .
• Or 18 mos. exp. as Workers' Compensation Claims Specialist, 16722, or managing caseload of workers' compensation lost-time disability claims which involved making decision to allow or deny claim, verifying appropriateness of medical treatment & charges, pre-authorized medical treatment, equipment, supplies & special travel arrangements, researching, negotiating, authorizing & issuing settlement of claims &/or conducting field inquiries to accurately assess claim information & resolving disputed condensability & benefit level for Ohio Bureau Of Workers' Compensation; 6 mos. exp. in operation of personal computer; valid driver's license. The final applicant accepted for this position must successfully pass state highway patrol personal background check prior to employment.
• Or 18 mos. exp. as BWC Fraud Investigator, 26261. Note: Pursuant to Ohio Administrative Code Chapter 4501 users of system shall adhere to policies & guidelines published in NCIC operating manual, CJIS security policy, LEADS operating manual, LEADS security policy, newsletters, & administrative messages from LEADS, all of which are either available on ODPS/LEADS intranet or disseminated to LEADS agencies; pursuant to LEADS security policy (revised 05/07/03) state & national fingerprint-based record checks must be conducted within 30 days of initial employment or assignment of all personnel, including appropriate IT personnel, having access to LEADS, or to records storage areas containing CCH/II data; minimum check must include submission of both a State of Ohio BCI& I card & an FBI applicant fingerprint card; both completed applicant fingerprint cards must be submitted by employing agency to State of Ohio Bureau of Criminal Identification & Investigation for processing & forwarding to Federal Bureau of Investigation; record of this check must be kept by employing agency & made available to LEADS upon request; fingerprint card returned by Ohio BCI&I is sufficient documentation. Pursuant to Ohio Administrative Code Chapter 4501 terminal agency shall conduct a complete background investigation of all terminal operators including, but not limited to: an applicant fingerprint card submission to BCI&I & FBI, an inquiry of state & national arrest & fugitive files; terminal agency is required to notify CTO of any applicant's criminal record; existence of a criminal record may result in denial of access.

Job Skills: Investigation

Major Worker Characteristics:

Knowledge of business; Criminal Justice; Humanities; Social & Behavioral Science Education or related field; BWC Policies & Procedures ; Laws & Regulations related to Adjudication & Maintenance of Workers' Compensation Claims ; Agency, State &/or Federal Statutes, rules, regulations & procedures applicable to investigation, evidence gathering, & search & seizure ; English; oral & written communication; public relations; interviewing techniques; principles of customer service; fundamental math operations; standard business practices; adult education, adult learning theory; RIM policies & procedures ; investigative procedures to effectively act as a field training officer

Skill in use of personal computer; word processor ; data base & spreadsheet software ; analytical software used in Fraud Detection ; surveillance equipment (e.g. camcorder; mini camera; undercover audio recording devices) .

Ability to communicate effectively & professionally with coworkers, injured workers, employers, legislators, health care providers, public, & external investigative partners; make complex decisions regarding claims activity; read & understand medical reference manuals; write clear, concise & professional correspondence & reports; collate & classify information about data, people or things; assess immediate situation & make split-second decisions; respond to sensitive inquiries from & contacts with injured workers, employers, legislators, health care providers & members of public; identify patterns, collect data, establish facts & draw valid conclusions

(*) Developed after employment.