Special Investigations Investigator, Consultant

Blue Shield of California•Oakland, CA

5d•Hybrid

About The Position

The Special Investigations Investigator, Consultant is a senior subject matter expert on the Special Investigations Unit (SIU), which prevents, detects, investigates, and resolves health care fraud, waste, and abuse. Reporting to the SIU Manager, this role conducts investigations for all lines of business in accordance with company policies and procedures and applicable laws and regulations. The position requires travel to provider locations for onsite audits as needed. The investigator handles complex and sensitive investigations, provides guidance and quality review to other investigators, and develops investigative standards and resources. The role also partners with law enforcement, regulators, and internal leadership on high-risk or high-impact cases; conducts medical record audits; coordinates recovery of erroneous payments; and prepares detailed investigative and post-audit reports with limited to no supervisory assistance. This is a hybrid role. For most teams, employees work in the office two days each week. Employees who live more than 50 miles from an office location will work with their manager to determine in-office time based on business needs.

Requirements

Bachelor’s degree, or a high school diploma/GED plus four years of additional relevant experience in lieu of a degree.
Seven years of prior relevant experience related to fraud, waste, and abuse.
Excellent presentation, interpersonal, and negotiation skills.
Proficiency in MS Office and data mining tools.
Extensive experience in health care, compliance, privacy, legal services, and/or investigations.
Excellent analytical and critical-thinking skills.
Excellent written and verbal communication and negotiation skills 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 to ensure 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.
Use expert discretion to ensure investigations align with legal, regulatory, and policy requirements.
Conduct medical record audits.
Travel to provider locations to conduct onsite audits as needed.
Initiate, analyze, develop, and complete complex fraud investigations, and communicate investigation and audit findings with limited to no supervisory assistance.
Coordinate and oversee efforts to recover erroneous payments resulting from claims processing errors, misrepresentative billing, fraud, abuse, or other criminal acts, without assistance.
Document all stages of each investigation using company and department procedures, templates, and forms.
Prepare detailed post-audit investigative reports.