Your Role

The Special Investigations Unit team is responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse. 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.

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 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
• 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

Your Knowledge and Experience

• Requires a college degree or equivalent experience and minimum 7 years of prior relevant experience
• Requires excellent analytical and critical thinking skills
• 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 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 stays
• Requires excellent written, oral, presentation, interpersonal, and negotiation skills
• Requires demonstrated knowledge and experience of Medicare, Medi-Cal, and other government programs.
• Requires proficiency in Microsoft Office. Experience with data mining systems, Business Objects, and SAS are a plus.
• Has obtained CPC or equivalent medical coding certification or the ability to obtain within 2 years of employment

Pay Range:

The pay range for this role is: $ 96470.00 to $ 144760.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.