What are the responsibilities and job description for the Special Investigations Analyst, Senior position at Blue Shield of CA?
Your Role
The Special Investigations Unit (SIU) is responsible for detecting, investigating, and preventing healthcare fraud, waste, and abuse involving providers, facilities, members, and brokers across all lines of business, and for coordinating with law enforcement and regulatory agencies. The Special Investigations Analyst, Senior will report to the Senior Manager, Special Investigations Unit. In this role you serve as the front of the SIU detection pipeline, independently identifying suspect providers and emerging fraud schemes through advanced data mining and claims analysis.
You will quantify financial exposure, develop well-supported lead packages, and drive the analysis that enables prepayment review placement, investigation, and payment containment. Your work directly protects members and reduces the cost of healthcare by stopping improper payments before they are made. This role requires travel to provider locations to conduct onsite provider audits, as needed.
Your Knowledge and Experience
Requires a bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree
Requires 5 years of prior relevant experience in healthcare fraud analytics, claims analysis, payment integrity, audit, or a related investigative or analytical field
Requires advanced knowledge of health insurance reimbursement methodologies, coding frameworks (CPT, HCPCS, ICD-10, revenue codes), and government program requirements; coding certification such as CPC preferred
Requires proven ability to apply independent analytic judgment to complex, ambiguous scenarios and quantify financial exposure or relevant metrics
Requires advanced ability to read, interpret, and synthesize medical documentation without routine assistance
Requires strong written, verbal, and presentation skills with limited guidance, including the ability to produce defensible documentation for internal, regulatory, and law enforcement audiences
Requires proficient use of advanced analytic tools, queries, and visualization techniques used for fraud detection; SQL, Excel, and claims platforms such as Facets
Experience with fraud detection platforms such as HCFS preferred
Knowledge of behavioral health and other fraud schemes preferred
Hybrid
This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.
Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.