Special Investigations Analyst, Senior

Blue Shield of CA; Long Beach (CA); Hybrid; USD 110,000 - 170,000; Full time

Job summary

Blue Shield of California seeks a Senior Special Investigations Analyst to detect and prevent healthcare fraud, waste, and abuse across lines of business. You'll lead analytics, quantify financial exposure, and develop lead packages enabling prepayment review, investigations, and containment.

Occasional travel for onsite audits may be required, with hybrid in-office expectations. Ideal candidates bring 5+ years of healthcare fraud analytics experience, strong knowledge of coding frameworks, and

Qualifications

• Bachelor's degree or HS Diploma/GED plus 4 years of additional relevant experience
• 5 years of prior relevant experience in healthcare fraud analytics, claims analysis, payment integrity, audit, or related investigative/analytical field
• Advanced knowledge of health insurance reimbursement methodologies, coding frameworks (CPT, HCPCS, ICD-10, revenue codes), and government program requirements; CPC preferred
• Ability to apply independent analytic judgment to complex, ambiguous scenarios and quantify financial exposure or relevant metrics
• Advanced ability to read, interpret, and synthesize medical documentation without routine assistance
• Strong written, verbal, and presentation skills with limited guidance
• Proficient use of advanced analytic tools, queries, and visualization techniques used for fraud detection; SQL, Excel, and claims platforms such as Facets
• Experience with fraud detection platforms such as HCFS preferred
• Knowledge of behavioral health and other fraud schemes preferred

Responsibilities

• Detect, investigate, and prevent healthcare fraud, waste, and abuse across lines of business
• Quantify financial exposure, develop lead packages, and drive analysis for prepayment review and containment
• Travel to provider locations to conduct onsite provider audits as needed
• Produce defensible documentation for internal, regulatory, and law enforcement audiences

Skills

SQL

Excel

Data analytics

Communication skills

Presentation skills

Education

Bachelor's degree or HS Diploma/GED plus 4 years experience

Tools

Facets

HCFS

Job description

Your Role

The Special Investigations Unit (SIU) is responsible for detecting, investigating, and preventing healthcare fraud, waste, and abuse involving providers, facilities, members, and brokers across all lines of business, and for coordinating with law enforcement and regulatory agencies. The Special Investigations Analyst, Senior will report to the Senior Manager, Special Investigations Unit. In this role you serve as the front of the SIU detection pipeline, independently identifying suspect providers and emerging fraud schemes through advanced data mining and claims analysis.

You will quantify financial exposure, develop well-supported lead packages, and drive the analysis that enables prepayment review placement, investigation, and payment containment. Your work directly protects members and reduces the cost of healthcare by stopping improper payments before they are made. This role requires travel to provider locations to conduct onsite provider audits, as needed.

Your Knowledge and Experience

• Requires a bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
• Requires 5 years of prior relevant experience in healthcare fraud analytics, claims analysis, payment integrity, audit, or a related investigative or analytical field
• Requires advanced knowledge of health insurance reimbursement methodologies, coding frameworks (CPT, HCPCS, ICD-10, revenue codes), and government program requirements; coding certification such as CPC preferred
• Requires proven ability to apply independent analytic judgment to complex, ambiguous scenarios and quantify financial exposure or relevant metrics
• Requires advanced ability to read, interpret, and synthesize medical documentation without routine assistance
• Requires strong written, verbal, and presentation skills with limited guidance, including the ability to produce defensible documentation for internal, regulatory, and law enforcement audiences
• Requires proficient use of advanced analytic tools, queries, and visualization techniques used for fraud detection; SQL, Excel, and claims platforms such as Facets
• Experience with fraud detection platforms such as HCFS preferred
• Knowledge of behavioral health and other fraud schemes preferred

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.