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Senior Investigator for Special Investigations Unit
2 months ago
Your Role
The Senior Investigator for the Special Investigations Unit (SIU) is pivotal in the fight against health care fraud, waste, and abuse. Reporting directly to the SIU Manager, this position demands a high level of professionalism and integrity, both within the organization and in external interactions. You will conduct thorough investigations in alignment with corporate policies and applicable legal standards.
Key Responsibilities
In this capacity, you will:
- Execute moderate to complex investigations while adhering to company protocols and legal requirements.
- Initiate, analyze, and finalize fraud investigations with minimal supervisory input.
- Establish and nurture relationships with SIU personnel from other insurance providers and law enforcement entities.
- Collaborate with various departments within Blue Shield of California to enhance investigative outcomes.
- Support efforts to recover incorrect payments due to claims processing errors, fraudulent activities, or other unlawful actions.
- Document all phases of investigations meticulously, utilizing company templates and preparing comprehensive post-audit reports.
- Handle sensitive information with the utmost confidentiality, ensuring compliance with privacy regulations.
- Work autonomously in a secure remote setting while also engaging effectively within a team structure.
- Exhibit excellent time management and organizational skills to prioritize tasks effectively.
- Adapt to flexible work schedules to meet investigation demands.
- Identify challenges, devise solutions, and implement effective action plans.
Required Knowledge and Experience
- A bachelor's degree or equivalent experience, with a strong background in health care, legal services, or a minimum of 5 years in investigative roles.
- Advanced understanding of health insurance reimbursement methods, including coding systems such as ICD-10 CM, CPT, and HCPCS.
- Strong analytical and critical thinking capabilities.
- In-depth knowledge of Commercial, Medicare, Medi-Cal, and other government programs.
- Proficient in investigative techniques typically acquired through advanced education or relevant work experience.
- Willingness to travel as necessary, including occasional overnight trips.
- Exceptional written, verbal, presentation, interpersonal, and negotiation skills.
- Experience with Facets, PIMS, and Microsoft Office; familiarity with Tableau and Business Objects is advantageous.
- Ability to interpret and understand medical documentation.
- Knowledge of medical coding; certification such as CPC or equivalent is preferred or the ability to obtain within two years of employment.
- Comprehensive understanding of all lines of business, including Medicare, Medi-Cal, and other government programs.
The compensation range for this position is competitive and reflective of the candidate's experience and location.
About the Organization
Blue Shield of California is committed to ensuring that all Californians have access to high-quality health care at an affordable price. We are dedicated to transforming health care to better serve our nonprofit mission by reducing costs, enhancing quality, and improving the experience for both members and providers. Our commitment to diversity, equity, and inclusion is integral to our values and mission, as we strive to create a healthcare system that addresses health disparities and promotes social justice.
Blue Shield has been recognized as a top employer and is committed to making a positive impact in our communities.
