Special Investigations Investigator, Consultant

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 110,000 - 160,000; Full time

Job summary

Blue Shield of CA is seeking a Special Investigations Investigator, Consultant to help prevent, detect, and resolve healthcare fraud, waste, and abuse across all lines of business. You will investigate cases, prepare findings, and report results to the SIU manager.

This role involves travel to provider locations for onsite audits and requires a strong background in healthcare compliance, coding, and data analysis.

Qualifications

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

Responsibilities

• Conduct investigations in accordance with company policies and laws
• Travel to provider locations to conduct onsite provider audits as needed
• Collaborate with SIU team and manager to resolve cases

Skills

MS Office

Data mining

Analytical thinking

Communication & negotiation

Interpersonal skills

Education

Bachelor's degree

High School Diploma or GED

Tools

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.