Qureos Mentor

Blue Shield of California

<div>Your Role 
The Special Investigations Unit (SIU) 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 conduct investigations in accordance with company policies and procedures and in compliance with all applicable laws and regulations.</div>
 <div>Your Work 
In this role, you will:
<ul><li>Initiate, analyze, develop, and successfully complete moderate to complex fraud investigations with limited supervisory assistance.
</li><li>Develop and maintain relationship with SIU personnel at other insurance carriers and law enforcement agencies
</li><li>Develop and maintain relationships with personnel from other business units and departments within Blue Shield of CA
</li><li>Responsible for supporting and coordinating efforts to recover erroneous payments made because of a claims processing error, misrepresentative billing, fraud, abuse or any other criminal act with limited assistance
</li><li>Document all stages of each investigation using Company and department procedures, templates and form. Prepare detailed post-audit investigative reports. Limited supervisory assistance needed
</li><li>Handle highly confidential and sensitive information while ensuring compliance with privacy policies
</li><li>Work independently in a secure remote environment with minimal supervision as well as function within team and corporate structure
</li><li>Prioritize and practice excellent time management and organizational skills
</li><li>Work flexible work schedules to accommodate investigations
</li><li>Identify problems, develop solutions, and implement a chosen course of action</li></ul></div>
 <div>Your Knowledge and Experience 
 
 
<ul><li>Requires a bachelor&rsquo;s degree or equivalent work experience, as well as thorough experience in health care, legal services or at least 7 years investigations experience
</li><li>Requires advanced knowledge of health insurance reimbursement methodologies, including ICD-10 CM, CPT and HCPCS coding
</li><li>Requires advanced knowledge and experience of Commercial, Medicare, Medi-Cal, and other government programs.
</li><li>Requires advanced knowledge of investigations typically obtained through advanced education and/or previous job experience
</li><li>Requires the ability to travel as required, including occasional overnight stays
</li><li>Requires excellent written, oral, presentation, interpersonal, and negotiation skills.
</li><li>Requires experience in fraud investigations.
</li><li>Requires the ability to read and understand medical documentation
</li><li>Requires the ability to work without written processes, procedures, or formal training program
</li><li>Requires knowledge and experience researching health plan records/systems</li></ul></div>
 <div></div>
 <div>ABOUT THE TEAM 
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
Our Values:
<ul><li>Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul>Our Workplace Model:
At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose &ndash; whether working in the office or through a hybrid approach &ndash; by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
<ul><li>Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:
</li></ul>o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
<ul><li>On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
</li></ul>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. 
Equal Employment Opportunity:
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.</div>

Special Investigations Investigator, Consultant

<div>Your Role 
The Promise Payment Integrity team leads the research and identification of financial integrity opportunities for Medi-Cal, not limited to the recoupment of provider overpayments, reinforce compliant claims payment processes, and ensure accurate revenue oversight and reconciliation. The Principal Business Analyst will report to the Director of Medi-Cal Performance Optimization. In this role you will blend deep claims data expertise with Medicaid/Medi-Cal policy know-how to deliver near-term recoveries and long-term solutions.</div>
 <div>Your Work
In this role, you will:
<ul><li>Develop and conduct evaluations and studies within limited time frames and produce analyses that are easy for non-technical persons to understand
</li><li>Apply advanced statistical methods, advanced analytics and modeling techniques, visualization techniques, and advanced programming to innovate our products and services
</li><li>Identify how our customers are using our products to make strategic decisions and generate/implement ideas to improve our products and services to allow even better decision support
</li><li>Identify &amp; size opportunities: Mine medical claims (header/line), remits, authorization, and provider data to detect overpayment patterns (e.g., duplicate, unbundling, DRG upcoding, place-of-service, COB, retro eligibility, NCCI edits)
</li><li>Lead recoveries end-to-end: Validate hypotheses, quantify impact, document case logic, and route to recovery&mdash;letters, offsets, refund processing, and tracking&mdash;ensuring timely, compliant collections
</li><li>Root-cause &amp; fix: Perform RCA on adjudication errors (pricing, benefits, provider setup, code edits, COB, policy gaps) and drive corrective actions in Facets configuration, claims editing, or business process changes (UAT + production readiness)
</li><li>Govern vendor &amp; internal programs: Own the day-to-day of assigned PI programs (internal and vendor-supported), monitor KPIs, backlog, and quality, and escalate issues; convert one-off &quot;finds&quot; into durable edit/rules
</li><li>Regulatory alignment: Ensure recoveries and edits align to Medicaid/Medi-Cal rules and plan contracts; partner with Compliance/Legal on policy interpretation and provider communications
</li><li>Cross-functional leadership: Partner with Claims Ops, Provider Contracting, Medical Management, SIU/FWA, and Finance on implementation, appeals, and provider education; present results to leadership
</li><li>Reporting &amp; storytelling: Build dashboards and narrative readouts: opportunity pipeline, identified/validated/recovered, yield, aging, and fix adoption</li></ul></div>
 <div>Your Knowledge and Experience
<ul><li>Requires mastery level knowledge of job area typically obtained through advanced education combined with experience. May have deep knowledge of project management
</li><li>Requires a bachelors degree or equivalent experience
</li><li>Requires at least 10 years of prior relevant experience
</li><li>Requires SQL expertise; strong Excel; experience with a viz tool (Power BI/Tableau) preferred
</li><li>Requires hands-on experience with claims systems (preferably Facets) - benefit, pricing, provider/network, and code-edit constructs; able to partner on config and UAT
</li><li>Medical Coding knowledge: working mastery of ICD-10-CM/PCS, CPT/HCPCS, DRG, modifiers, NCCI, POS, revenue codes. Certifications (CPC, COC, CPMA) is preferred
</li><li>Medicaid/Medi-Cal payment policy familiarity (coordination of benefits, retro eligibility, rate/benefit nuances, prior auth, state policy bulletins) is preferred
</li><li>Prior experience in a California plan with Medi-Cal (DHCS) lines of business, exposure to vendor PI programs (post-pay, pre-pay, DRG validation, coding audits) and FWA/SIU collaboration is preferred</li></ul></div>
 <div></div>
 <div>ABOUT THE TEAM 
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
Our Values:
<ul><li>Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul>Our Workplace Model:
At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose &ndash; whether working in the office or through a hybrid approach &ndash; by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
<ul><li>Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:
</li></ul>o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
<ul><li>On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
</li></ul>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. 
Equal Employment Opportunity:
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.</div>

Business Analyst, Principal - Payment Integrity

<div>Your Role 
The Network and Provider Analytics team drives the development of an affordable provider network through data analytics and expertise . The Actuarial Analyst, Experienced will report to the Senior Manager. In this role you will perform financial analyses and modeling for provider contracting support including term changes, renewals, network changes, and terminations for hospitals, ambulatory surgery centers, professional, IPA/MG, and other types of providers .</div>
 <div>Your Work 
In this role, you will:
<ul><li>Understand the core principles and functionality of decision, descriptive, predictive and prescriptive analytic methods including forecasting, statistical and machine learning techniques
</li><li>Conduct and develop analysis, assess risk and population risk scores and assignment, develop pricing and trends, assess changes in benefit designs, develop reserves, perform forecasting, analyze provider reimbursement terms and/or evaluates actuarial risk related analysis
</li><li>Coordinate, prepare, perform and audit actuarial analyses to assist in the development of complex actuarial formulations leading to the recommendation of pricing, trending, reserving, provider reimbursement and/or risk assessment strategies
</li><li>Perform data exploration using a combination of statistical programming languages (including, but not limited R, Python, SQL, SAS) and deploy predictive analytics and machine learning techniques to improve risk prediction, improve reserve, trend and financial forecasting in a manner that is actuarially sound, and enable real-time results and operational efficiencies
</li><li>Direct, coordinate, and/or develop evaluation and financial reporting standards for internal and external reports
</li><li>Create financial unit cost trend reporting and rate calculations using Excel modeling tools
</li><li>Reprice historical data against provider contract terms based on deep understanding on contract structure and configuration
</li><li>Analyze contract rate proposals from hospitals and ambulatory surgery centers to assess the financial and trend impact
</li><li>Partner with network management department in maintaining and developing the provider network and contracting strategy</li></ul></div>
 <div>Your Knowledge and Experience 
 
 
<ul><li>Requires a bachelor&rsquo;s degree with at least a minor in mathematics, statistics, computer science or equivalent business experience
</li><li>Requires at least 2 years of professional actuarial experience
</li><li>Requires experience analyzing healthcare claims data, trends, and forecasting
</li><li>Requires proficiency in Excel and comfort working with large data sets
</li><li>Knowledge of SAS is preferred</li></ul></div>
 <div></div>
 <div>ABOUT THE TEAM 
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
Our Values:
<ul><li>Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul>Our Workplace Model:
At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose &ndash; whether working in the office or through a hybrid approach &ndash; by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
<ul><li>Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:
</li></ul>o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
<ul><li>On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
</li></ul>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. 
Equal Employment Opportunity:
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.</div>

Actuarial Analyst, Experienced

<div>Your Role
The Cash Operations team manages the posting of cash receipts, check management functions for disbursements, and the accounting for all receipts and disbursements. The AP Collections Billing Support, Intermediate role will report to the Cash Receiving Supervisor. In this role you will be ensuring the efficient and accurate recording of cash receipts and performing periodic analysis to support audit functions.</div>
 <div>Your Work
In this role, you will:
<ul><li>Maintain and reconcile records and account files and perform related accounting activities
</li><li>Gather payment and/or reference information, maintain database (enter, update, retrieve data; format and generate reports), and apply adjustments as necessary
</li><li>Research, verify and enter related information to automated financial systems; check accuracy of input and make corrections, as needed
</li><li>Prepare comparison/trend analysis reports for management review; prepare monthly collections reports
</li><li>Assist in the identification and deposits of additional non-premium payments received
</li><li>Review internal/ external reports and identify/ correct discrepancies
</li><li>Coordinate internally and externally to resolve payment problems and monitor and report on related activities
</li><li>Propose procedural and reporting enhancements
</li><li>Participate in special projects as assigned</li></ul></div>
 <div>Your Knowledge and Experience
<ul><li>Requires a high school diploma or GED
</li><li>Requires at least 1 year of related accounts payable/receivable experience or training
</li><li>Requires basic job knowledge of systems and procedures obtained through prior work experience or education
</li><li>BA/BS in Accounting, Finance, or related field preferred
</li><li>Claims processing or customer service experience highly desired
</li><li>Two years&rsquo; experience using Facets system for research and entry of premium payments highly desired
</li><li>Proficiency in Microsoft Office (especially Excel but also Word and Outlook)
</li><li>Previous experience in healthcare accounting functions preferred</li></ul></div>
 <div></div>
 <div>ABOUT THE TEAM 
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities &ndash; join us!
Our Values:
<ul><li>Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
</li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul>Our Workplace Model:
At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose &ndash; whether working in the office or through a hybrid approach &ndash; by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
<ul><li>Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:
</li></ul>o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
<ul><li>On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
</li></ul>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. 
Equal Employment Opportunity:
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.</div>

Accounting Support, Intermediate

Join Blue Shield of California and explore 4   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Blue Shield of California

ABOUT_COMPANY

Special Investigations Investigator, Consultant

Business Analyst, Principal - Payment Integrity

Actuarial Analyst, Experienced

Accounting Support, Intermediate