Special Investigations Investigator, Consultant

Your Role The Special Investigations Unit (SIU) team s responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse. The Special Investigations Investigator, Consultant report 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. Your Knowledge and Experience 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 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. #J-18808-Ljbffr Blue Shield of CA