Special Investigations Investigator, Senior

Your Role

 

The Special Investigations Unit (SIU) team is responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse. The Special Investigations Investigator, Senior will 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.

Your Work

 

In this role, you will:

• Initiate, analyze, develop, and successfully complete moderate to complex fraud investigations with limited supervisory assistance.
• Develop and maintain relationship with SIU personnel at other insurance carriers and law enforcement agencies
• Develop and maintain relationships with personnel from other business units and departments within Blue Shield of CA 
• Responsible for supporting and coordinating efforts to recover erroneous payments made because of a claims processing error, misrepresentative billing, fraud, abuse or any other criminal act with limited assistance
• Document all stages of each investigation using Company and department procedures, templates and form. Prepare detailed post-audit investigative reports. Limited supervisory assistance needed
• Handle highly confidential and sensitive information while ensuring compliance with privacy policies
• Work independently in a secure remote environment with minimal supervision as well as function within team and corporate structure
• Prioritize and practice excellent time management and organizational skills
• Work flexible work schedules to accommodate investigations
• Identify problems, develop solutions, and implement a chosen course of action

Your Knowledge and Experience

 

• Requires a bachelor’s degree or equivalent work experience as well as thorough experience in health care, legal services or at least 5 years investigations experience
• Requires advanced knowledge of health insurance reimbursement methodologies, including ICD-10 CM, CPT and HCPCS coding
• ​​Requires advanced knowledge and experience of Commercial, Medicare, Medi-Cal, and other government programs. ​
• Requires advanced knowledge of investigations typically obtained through advanced education and/or previous job experience 
• Requires the ability to travel as required, including occasional overnight stays
• Requires excellent written, oral, presentation, interpersonal, and negotiation skills.
• Requires experience with Facets, PIMS, and Microsoft Office. Experience with Tableau is a plus
• Requires the ability to read and understand medical documentation
• Requires the ability to work without written processes, procedures, or formal training program