Special Investigations Investigator, Consultant

Job Description

Your Role

The Special Investigations Unit (SIU) team is responsible for investigations of suspected fraud, waste or abuse involving health care providers, facilities, subscribers, brokers and/or employer groups. Serve as a liaison with law enforcement and regulatory agencies. Coordinate with internal business units and other health plans. The Special Investigations Investigator Consultant will report to the SIU Manager. In this role you will represent a high level of professionalism both internally and externally. Conduct investigations in accordance with company policies and procedures and in compliance with all applicable laws and regulations.

Responsibilities

Your Work

In this role, you will:

• Initiate, analyze, develop, and successfully complete complex fraud investigations with limited to no supervisory assistance.
• Develop and maintain relationships 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
• Be responsible for coordinating and overseeing efforts to recover erroneous payments made because of a claims processing error, misrepresentative billing, fraud, abuse or any other criminal act with no assistance
• Document all stages of each investigation using Company and department procedures, templates and form. Prepare detailed post-audit investigative reports. Limited to no 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.

Qualifications

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires a minimum of 7 years of prior relevant experience, inclusive of experience with health insurance claims, medical coding experience, and investigative experience
• Requires deep knowledge of investigations typically obtained through advanced education combined with experience
• Typically, viewed as a specialist within discipline. May have broad knowledge of project management
• Requires FACETS experience
• Requires extensive knowledge of health insurance reimbursement methodologies, including ICD-10 CM, CPT and HCPCS coding
• Requires the ability to travel as required, including occasional overnight stay
• Requires proficiency in Microsoft Office, experience with Tableau, and Excel spreadsheets with pivot tables.
• Requires the ability to read and understand medical documentation
• Requires excellent analytical and critical thinking skills
• Requires CPC or equivalent medical coding certification or the ability to obtain within 2 years of employment
• Requires knowledge and experience of Medicare, Medi-Cal, and other government programs.
• Requires excellent written and verbal communication skills for correspondence and negotiations with attorneys and providers

About the Team

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:

o Member-facing and approved out-of-state roles remain remote.

o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.