Michelle Emmons

Senior Investigator @Wellmark Blue Cross and Blue Shield

Des Moines, IA, US

Under the direction of Leadership, identify and investigate suspected health insurance fraud and abuse, identify potential losses and recoveries for the corporation, prepare reports of suspected fraud and abuse, and work with law enforcement agencies and anti-fraud organizations as appropriate. Investigations much be conducted in accordance with company policies and procedures and in compliance with all applicable laws and regulations.Functions include:oEvaluate allegations of fraud and abuse from members, providers, other Plans and law enforcement by utilizing data analysis tools such as creating new and existing Business Objects reports, fraud software and web based searches. o Utilize fraud and abuse detection software, other data sources and leads to identify or substantiate patters of suspected irregular health insurance activity proactively.oDetermine if provider and/or member interviews are needed, develop script and conduct interviews.oPrepare letters to communicate to providers concerning decisions and provide education based on provider billing guide, medical policy and correct coding in collaboration with other departments such as health management and provider network relations.oInteract professionally with providers, members and other contacts both verbally and in written communication.