Senior Investigator for Special Investigations Unit

2 weeks ago

Oakland, California, United States Blue Shield Of California Full time

Position Overview

The Senior Investigator within the Special Investigations Unit (SIU) plays a crucial role in the identification, examination, and resolution of fraudulent activities related to healthcare. Reporting directly to the SIU Manager, this position demands a high standard of professionalism and integrity in all interactions, both internally and externally. You will be responsible for conducting thorough investigations that adhere to company policies and comply with relevant laws and regulations.

Key Responsibilities

In this capacity, your duties will include:

  • Executing moderate to complex investigations in line with established company protocols and legal requirements.
  • Initiating, analyzing, and concluding investigations with minimal oversight, ensuring thoroughness and accuracy.
  • Building and nurturing relationships with SIU teams from other insurance providers and law enforcement agencies.
  • Collaborating with various departments within Blue Shield of California to enhance investigative efforts.
  • Assisting in the recovery of erroneous payments due to claims processing errors, fraudulent billing, or other unlawful activities.
  • Documenting all phases of investigations meticulously, utilizing company templates and procedures, and preparing comprehensive post-audit reports.
  • Handling sensitive and confidential information while maintaining strict adherence to privacy regulations.
  • Working autonomously in a secure remote setting, while also being an effective team player.
  • Demonstrating exceptional time management and organizational skills to prioritize tasks effectively.
  • Adapting to flexible work schedules to meet the demands of ongoing investigations.
  • Identifying challenges, devising solutions, and executing chosen strategies.

Qualifications and Skills

  • A bachelor’s degree or equivalent professional experience, complemented by extensive knowledge in healthcare, legal services, or a minimum of five years in investigative roles.
  • In-depth understanding of health insurance reimbursement processes, including coding systems such as ICD-10 CM, CPT, and HCPCS.
  • Strong analytical and critical thinking capabilities.
  • Advanced knowledge of various government programs, including Commercial, Medicare, and Medi-Cal.
  • Proficiency in investigative techniques acquired through advanced education or relevant experience.
  • Willingness to travel as necessary, including occasional overnight trips.
  • Excellent communication skills, both written and verbal, along with strong presentation and negotiation abilities.
  • Familiarity with software such as Facets, PIMS, and Microsoft Office; experience with Tableau and Business Objects is advantageous.
  • Ability to interpret and understand medical documentation.
  • Knowledge of medical coding; certification such as CPC or the ability to obtain it within two years of employment is preferred.
  • Comprehensive understanding of all lines of business, including Medicare and Medi-Cal.

Compensation Information

The compensation range for this position is competitive and reflects the market standards for similar roles within California.

Additional Information

This compensation range is indicative of the salary for this position and others within the same pay grade at Blue Shield. Salaries are determined based on various factors, including the candidate's experience and location.

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