Special Investigations Investigator, Consultant

Blue Shield of CA; Long Beach (CA); Hybrid; USD 110.000 - 160.000; Vollzeit

Zusammenfassung

Blue Shield of CA is seeking a Special Investigations Investigator, Consultant to lead investigations into health care fraud, waste and abuse. The role reports to the SIU manager, conducts audits at provider sites, and travels as needed to ensure compliance with policies and regulations.

The ideal candidate will bring extensive healthcare compliance and investigations experience, strong analytical and negotiation skills, and the ability to work independently with minimal guidance.

Qualifikationen

• Requires 7 years of experience in fraud, waste, and abuse.
• Extensive experience in health care, compliance, privacy, legal services, and investigations.
• Deep knowledge of reimbursement programs and audits of medical documentation.
• Excellent written and verbal communication and negotiation without guidance.
• Strong presentation, interpersonal, and negotiation skills.
• Proficiency in MS Office and data mining tools.

Aufgaben

• Conduct investigations in accordance with company policies and applicable laws.
• Investigate, prevent, detect, and resolve health care fraud, waste, and abuse.
• Prepare reports and updates for the SIU manager.
• Travel to provider locations for onsite provider audits as needed.
• Collaborate with cross-functional teams to ensure compliance.

Kenntnisse

Presentation skills

Interpersonal skills

Negotiation

Analytical thinking

Communication

Claim review

Coding knowledge

Auditing medical documentation

Reimbursement knowledge

Healthcare compliance

Ausbildung

Bachelor's degree or High School Diploma/GED with 4 years relevant experience in lieu of a degree

Tools

MS Office

Data mining tools

Jobbeschreibung

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.