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
• 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

Last updated : 2024-05-10