Your Role

The Special Investigations Unit (SIU) comprises several areas that, in collaboration, are tasked to identify, investigate, and combat health insurance fraud, waste and abuse (FWA). SIU's Prepayment Review team is responsible for ongoing review of claims, clinical records, and other documents submitted by subjects under ongoing investigation by the SIU. The Manager, Special Investigations Unit/Prepayment Review, will report to the Senior Director, Special Investigations Services. In this role you will establish and manage a team of experts that can identify FWA indicators or patterns in claims and medical records.

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires a minimum 7 years prior relevant experience
• Requires health care fraud investigations experience
• Requires 3 years of management experience gained as a team leader, supervisor or project/program manager
• Requires advanced knowledge of job area usually obtained through advanced education combined with experience
• Requires the understanding of basic management approaches such as work scheduling, prioritizing, coaching and process execution, work organization, risk management and delegation
• Requires the understanding of Blue Shield of CA's mission and business plan
• Requires functional expertise within the area of responsibility
• Certified Coder and/or Accredited Healthcare Fraud Investigator certification required
• Requires excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines
• Requires one to be a team player, entrepreneurial, resourceful, and results-oriented
• Requires knowledge of investigative techniques along with the ability to organize, analyze, and effectively determine risk with corresponding solutions
• Requires proficiency in Microsoft Office, SQL and Tableau

Pay Range:

The pay range for this role is: $ 96470.00 to $ 144760.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.