Special Investigations Analyst, Senior

Blue Shield of CA; Oakland (CA); Hybrid; USD 120,000 - 150,000; Full time

Job summary

Blue Shield of California in Oakland, CA seeks a Senior Special Investigations Analyst to detect and prevent healthcare fraud. You will independently identify suspect providers and emerging schemes through advanced data mining and claims analysis, quantifying financial exposure and building lead packages for prepayment review.

Requires 5 years of relevant experience, advanced coding knowledge, and strong communication skills. Hybrid in-office schedule with two days on site per week.

Qualifications

• Bachelor's degree or High School Diploma/GED with 4 years of relevant experience.
• 5 years of prior healthcare fraud analytics or related investigative experience.
• Advanced knowledge of health insurance reimbursement methods and coding (CPT/HCPCS/ICD-10).
• Ability to quantify financial exposure and present defensible documentation.
• Ability to read, interpret, and synthesize medical documentation.
• Strong written, verbal, and presentation skills with limited guidance.
• Proficiency in analytics tools and fraud detection platforms (SQL, Excel, Facets).
• Experience with HCFS fraud detection platform is preferred.
• Knowledge of behavioral health fraud schemes is a plus.

Responsibilities

• Detect, investigate, and prevent healthcare fraud, waste, and abuse.
• Independently identify suspect providers and fraud schemes via data mining and claims analysis.
• Quantify financial exposure and develop lead packages for prepayment review.
• Drive analysis for investigation and payment containment across lines of business.
• Prepare defensible documentation for internal, regulatory, and law enforcement audiences.
• Collaborate with SIU and law enforcement; coordinate with regulatory agencies.

Skills

SQL

Excel

Fraud analytics

Data mining

Claims analysis

Presentation

Communication

Education

Bachelor's degree

High School Diploma/GED

Tools

Facets

HCFS

CPT/HCPCS/ICD-10 knowledge

Job description

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.

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.