Special Investigations Investigator, Consultant

Blue Shield of CA; Lodi (CA); Hybrid; USD 110,000 - 140,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Special Investigations Investigator, Consultant to join the SIU team. The role focuses on preventing, detecting, investigating, and resolving health care fraud, waste, and abuse across all lines of business.

Travel to provider locations for onsite audits is required, with a hybrid in-office schedule and typical two days per week in the office. Ideal candidates bring 7+ years of fraud-related experience, strong presentation and negotiation skills, and deep

Qualifications

• Bachelor's degree or GED with 4 years of relevant experience in lieu of a degree.
• Requires 7 years of prior relevant experience related to fraud, waste, and abuse.
• Requires excellent presentation/interpersonal/negotiation skills.
• Requires proficiency in MS Office and data mining tools.
• Requires extensive experience in health care, compliance, privacy, legal services, and/or investigations.
• Requires deep knowledge of reimbursement/program(s).
• Requires extensive experience of claim review and coding knowledge.
• Requires extensive knowledge in auditing medical documentation to substantiate services billed on a claim(s).
• Requires excellent analytical and thinking skills.
• Requires excellent written and verbal communication and negotiation without guidance.

Skills

Interpersonal skills

Negotiation

Analytical thinking

Written communication

Verbal communication

Education

Bachelor's degree or GED with 4 years' relevant experience in lieu of degree

Tools

MS Office

Data mining tools

Job description

Your Role

The Special Investigations Unit (SIU) team s responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse. The Special Investigations Investigator, Consultant report to the SIU manager. In this role you will conduct investigations in accordance with company policies and procedures and in compliance with all applicable laws and regulations; for all lines of business. This role requires travel to provider locations to conduct onsite provider audits, as needed.

Your Knowledge and Experience

• Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
• Requires 7 years of prior relevant experience related to fraud, waste, and abuse
• Requires excellent presentation/interpersonal/negotiation skills
• Requires proficiency in MS Office and data mining tools
• Requires extensive experience in health care, compliance, privacy, legal services, and or investigations
• Requires deep knowledge of reimbursement/program(s)
• Requires extensive experience of claim review and coding knowledge
• Requires extensive knowledge in auditing medical documentation to substantiate services billed on a claim(s)
• Requires excellent analytical and thinking skills
• Requires excellent written and verbal communication and negotiation without guidance

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.