Special Investigations Investigator, Consultant

Blue Shield of California • Rancho Cordova, CA

2d • Hybrid

About The Position

The Special Investigations Unit (SIU) team is responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse. The Special Investigations Investigator, Consultant reports 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 for all lines of business. This role requires travel to provider locations to conduct onsite provider audits, as needed.

Requirements

• Bachelor’s degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
• Requires 7 years of prior relevant experience related to fraud, waste, and abuse
• Requires excellent presentation/interpersonal/negotiation skills
• Requires proficiency in MS Office and data mining tools
• Requires extensive experience in health care, compliance, privacy, legal services, and or investigations
• Requires deep knowledge of reimbursement/program(s)
• Requires extensive experience of claim review and coding knowledge
• Requires extensive knowledge in auditing medical documentation to substantiate services billed on a claim(s)
• Requires excellent analytical and thinking skills
• Requires excellent written and verbal communication and negotiation without guidance

Responsibilities

• Serve as a senior subject matter expert handling the most complex and sensitive investigations
• Provide expert guidance, mentoring, and quality review for investigators, ensuring consistency, defensibility, and audit readiness
• Establish and maintain investigative standards, tools, templates, and training resources to improve team effectiveness
• Partner strategically with law enforcement, regulators, and internal leadership to support high risk or high impact cases
• Apply expert discretion to ensure investigations align with legal, regulatory, and policy requirements
• Conduct medical record audits
• Travel to provider locations to conduct onsite audits
• Initiate, analyze, develop and successfully complete complex fraud investigations and communicate investigation and audit findings with limited to no supervisory assistance
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Senior