Special Investigations Investigator, Consultant

Blue Shield of California•Oakland, CA

1d•$115,940 - $173,972•Hybrid

About The Position

The Special Investigations Investigator, Consultant is part of the Special Investigations Unit, which prevents, detects, investigates, and resolves health care fraud, waste, and abuse across all lines of business. The role reports to the SIU Manager and conducts investigations under company policies and procedures and applicable laws and regulations. Travel to provider locations is required as needed to conduct onsite audits. This senior-level role handles complex and sensitive investigations, provides guidance and quality review to investigators, and develops standards and resources to improve team effectiveness. The position also works with law enforcement, regulators, and internal leaders on high-risk or high-impact cases, and applies discretion to ensure investigative work meets legal, regulatory, and policy requirements. The role uses a hybrid workplace model. Most teams are expected to work in the office two days each week. Employees located more than 50 miles from an office work with their manager to determine in-office time based on business needs. The physical environment is an office and work-from-home deskwork setting, with a sedentary activity level for most of the workday.

Requirements

Bachelor’s degree, or a high school diploma/GED and four additional years of 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 the ability to negotiate 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 promote consistency, defensibility, and audit readiness.
Establish and maintain investigative standards, tools, templates, and training resources to improve team effectiveness.
Partner 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.
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 arising from claims processing errors, misrepresentative billing, fraud, abuse, or other criminal acts, without assistance.
Document all stages of investigations using company and department procedures, templates, and forms.
Prepare detailed post-audit investigative reports with limited to no supervisory assistance.