Job Description

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.

Responsibilities

Your Work

In this role, you will:

• Lead development of complex fraud leads within the Individual & Family Plan (IFP) line of business, linking and analyzing multiple datasets to identify underlying schemes, trends, and financial exposure, with focus on substance use disorder and behavioral health provider fraud
• Build and maintain detection queries, analytic models, and repeatable workflows that identify suspect providers, aberrant billing patterns, and rapid claim-volume escalation
• Quantify provider-level financial exposure and produce high quality, audit ready lead and case packages that support SIU prioritization and investigative decision making
• Apply judgment to resolve ambiguous analytic problems and deliver well supported lead recommendations, including prepayment review placement
• Communicate complex analytic findings and recurring program reporting clearly to SIU leadership and cross-functional stakeholders with limited guidance
• Provide guidance, coaching, and quality review for other analysts on complex analyses and documentation standards
• Partner with investigators, prepayment review staff, SIU leadership, Medical Directors, and internal business units to advance cases toward disposition
• Ensure all data gathering, analysis, and documentation comply with applicable state and federal regulations and Blue Shield privacy and information security requirements
• Other duties as assigned

Qualifications

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.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.