special investigator

Blue Shield of California

<div><p><b>Your Role<br>
</b></p><p></p><p>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.</p></div><p></p>
<br><div><p><b>Your Work<br>
</b></p><p></p><p>In this role, you will:
</p><ul><li><p>Initiate, analyze, develop, and successfully complete moderate to complex fraud investigations with limited supervisory assistance.
</p></li><li><p>Develop and maintain relationship with SIU personnel at other insurance carriers and law enforcement agencies
</p></li><li><p>Develop and maintain relationships with personnel from other business units and departments within Blue Shield of CA
</p></li><li><p>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
</p></li><li><p>Document all stages of each investigation using Company and department procedures, templates and form. Prepare detailed post-audit investigative reports. Limited supervisory assistance needed
</p></li><li><p>Handle highly confidential and sensitive information while ensuring compliance with privacy policies
</p></li><li><p>Work independently in a secure remote environment with minimal supervision as well as function within team and corporate structure
</p></li><li><p>Prioritize and practice excellent time management and organizational skills
</p></li><li><p>Work flexible work schedules to accommodate investigations
</p></li><li><p>Identify problems, develop solutions, and implement a chosen course of action</p></li></ul></div><p></p>
<br><div><p><b>Your Knowledge and Experience<br>
</b><br>
<br>
</p><ul><li><p>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
</p></li><li><p>Requires advanced knowledge of health insurance reimbursement methodologies, including ICD-10 CM, CPT and HCPCS coding
</p></li><li><p>Requires advanced knowledge and experience of Commercial, Medicare, Medi-Cal, and other government programs.
</p></li><li><p>Requires advanced knowledge of investigations typically obtained through advanced education and/or previous job experience
</p></li><li><p>Requires the ability to travel as required, including occasional overnight stays
</p></li><li><p>Requires excellent written, oral, presentation, interpersonal, and negotiation skills.
</p></li><li><p>Requires experience in fraud investigations.
</p></li><li><p>Requires the ability to read and understand medical documentation
</p></li><li><p>Requires the ability to work without written processes, procedures, or formal training program
</p></li><li><p>Requires knowledge and experience researching health plan records/systems</p></li></ul></div>
<br><div></div>
<br><p></p><div><p><b>ABOUT THE TEAM<br>
About Blue Shield of California
</b></p><p>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.
</p><p>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.
</p><p>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.
</p><p>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!
</p><p><b>Our Values:
</b></p><p></p><ul><li><b>Honest. </b>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><b>Human. </b>We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
</li><li><b>Courageous. </b>We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
</li></ul><p><b>Our Workplace Model:
</b></p><p>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.
</p><p>Two Ways of Working:
</p><p></p><ul><li><b>Hybrid (Default): </b>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><p></p><p>o Member-facing and approved out-of-state roles remain remote.
</p><p>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.
</p><p>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.
</p><ul><li><b>On-Site: </b>Work from a business unit-approved office an average of four (4) or more days a week.
</li></ul><p><b>Physical Requirements:
</b></p><p>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.</p><p><br>
</p><p><b>Equal Employment Opportunity:
</b></p><p>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.</p></div>

Special Investigations Investigator, Consultant

Core specialty

<div><div>Multi-state commercial insurance carrier is seeking a Senior SIU Investigator. The SIU Senior Investigator reviews and investigates referrals to the SIU to identify suspicious indicators of potential fraud committed by claimants, insureds, agents, brokers, providers and attorneys and conducts investigations of varying complexity. This is a remote position and reports to the SIU Manager. The ideal candidate will have proficiency in investigating claims across multiple lines of business to include Workers Compensation.</div><div></div><div>
Key Accountabilities/Deliverables:</div><ul><li><div>
Evaluate SIU referrals to establish if there are suspicious elements present that might warrant a SIU investigation and prepare concise investigative plans of action.</div></li><li><div>
Review claims via analytics programs to establish if SIU involvement is warranted</div></li><li><div>
Submit assignments to vendors for various investigative tasks when warranted and manage those assignments while controlling costs.</div></li><li><div>
Obtain, evaluate, and act on information and documentation received and communicate effectively with the claims staff, other insurance carriers, and law enforcement organizations such as the NICB, Department of Insurance, etc.</div></li><li><div>
Conduct data analysis and utilize analytical tools to identify suspicious claims.</div></li><li><div>
Prepare and submit investigative reports detailing and documenting all phases of an investigation to assist in the resolution of the claim.</div></li><li><div>
Compile and submit referrals to the NICB, Departments of Insurance, and other law enforcement agencies as warranted, clearly summarizing the investigation, and detailing the suspected fraud</div></li><li><div>
The investigator must understand and exhibit appropriate investigative behaviors and methods while conducting investigations, including development of the facts, due diligence with evidence collection, and conducting interviews both recorded and non-recorded.</div></li><li><div>
Effective time management skills, proactive execution of investigative plans, and flexibility are necessary to ensure the effectiveness of this position.</div></li></ul><div></div><div>
Technical Knowledge and Understanding:</div><ul><li><div>
Intermediate to Advanced Microsoft Office Skills/ multiple software applications, fluent with multiple investigative computer programs such as TLO, ISO, Accurint, etc.</div></li><li><div>
Excellent oral, written, and interpersonal communication skills are required</div></li><li><div>
Must be customer service oriented, highly organized and efficient</div></li></ul><div><ul><li><div>
Detailed-oriented with the ability to work in a team environment and be flexible to daily changing needs and job duties.</div></li><li><div>
Ability to analyze and solve problems, working closely with others to coordinate and complete projects</div></li><li><div>
Spanish / multiple language skills are preferred</div></li></ul></div><div></div><div>
Experience:</div><ul><li><div>
Bachelor&rsquo;s degree is preferred</div></li><li><div>
Minimum of 3 years of SIU-related experience for an insurance company and/or law enforcement investigative experience, or an equivalent combination of education and experience, is required</div></li><li><div>
Experience in conducting Workers Compensation claims / SIU investigations is preferred</div></li><li><div>
Industry-related professional designations such as FCLS, FCLA, and/or CIFI are preferred</div></li></ul><div></div><div>
Applicants must be authorized to work for any employer in the U.S. We are unable to sponsor or take over sponsorship of an employment Visa for this position.</div><div></div><div>
#LI-Remote</div><div></div><ul><li></li></ul><div>
At Core Specialty, you will receive a competitive salary and opportunities for professional development and advancement. We offer medical, dental, vision, and life insurances; short and long-term disability; a Company-match of 100% of a 6% contribution 401(k) plan; an Employee Assistance Plan; Health Savings Account, Flexible Spending Account, Health Reimbursement Account, and a wellness program</div></div>

Sr. SIU Investigator

Collin County Government

JOB
<br>Job DescriptionCollin County is seeking candidates for the position of a Financial Crimes Prosecutor. Work is performed under the direction of the 1st Assistant District Attorney. The Financial Crimes Prosecutor position will: Manage felony level offenses and complaints for Financial Crimes, Elder Fraud, and Public Integrity/Election Violations. Investigate complaints and cases of a particularly sensitive and confidential nature. Have the experience needed to work independently and without a regular prosecutorial support team.Manage the trial team secretary, investigator, and felony prosecutor in the court in which these cases are filed, to the extent their participation relates to this caseload. Expected to be able to manage the Financial Crimes Unit as it grows within the department and any future positions added to the Unit in the future. Manage the court calendar, conduct hearings, file and respond to motions, produce discovery, and conduct plea negotiations. Prepare cases for trial by interviewing witnesses and relevant parties, conducting investigations, conducting legal research, preparing trial exhibits, and composing legal documents. Try felony criminal cases to verdict. Work closely with law enforcement agencies, such as federal and state agencies, governmental entities, and elected officials. Perform all ancillary tasks.Requires specialized knowledge in the areas of Financial Crimes, Public Integrity, and Elder Fraud. Ability to handle this highly specialized and time-intensive caseload, work independently, and temporarily oversee, on a case-by-case basis, a large number of felony prosecutors, investigators, and support staff, to the extent their participation relates to this caseload. Bachelor’s degree is required. Must have a Doctorate of Jurisprudence and be licensed by the State of Texas to practice law. Must have prior experience as a Felony Prosecutor. Prior experience as a Chief Felony Prosecutor preferred.

Special Unit Prosecutor- Financial Crimes

USAA

<p><b>Why USAA?</b></p><p>At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the choice for the military community and their families.</p><p>Embrace a fulfilling career at USAA, where our core values - honesty, integrity, loyalty and service - define how we treat each other and our members. Be part of what truly makes us special and impactful.</p><p><b>The Opportunity</b></p><p>We are looking for a Manager, SIU (Special Investigations Unit) within P&C. Responsible for operational management of Claims fraud investigative teams. Directs staff in the investigation of cases involving questionable, suspect, or fraudulent activity. Ensures compliance with policies and procedures contributing to fraud control objectives, as well as compliance with state insurance fraud-related laws and regulations.</p><p>This role is remote eligible in the continental U.S. with occasional business travel.</p><p><b>What you'll do:</b></p><ul><li>Responsible for insurance fraud detection and investigation services to reduce fraud-related claim payments and costs, while avoiding unwarranted risk.</li><li>Ensures compliance with laws and regulations relating to claims handling and unfair claims practices and reporting statutes.</li><li>Participates in the establishment and implementation of policies and procedures for fraud control and investigative practices.</li><li>Performs leadership and management tasks, i.e., providing coaching, evaluating performance, review of time sheets, managing time off, conducting quarterly check-ins/ride-alongs, etc.</li><li>Evaluates, authorizes, and implements actions and decisions to carry out proactive claim's projects and investigations.</li><li>Reviews and evaluates investigation recommendations from investigators to ensure results and case documentation support conclusions.</li><li>Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.</li></ul><b>What you have:</b><ul><li>Bachelor's degree; OR 4+ years of related experience (in addition to the minimum years of experience required) may be substituted in lieu of degree.</li><li>6+ years P&C industry functional work experience OR 4+ years of P&C experience plus military service experience.</li><li>2+ years of demonstrated leadership experience, supervisory or management experience.</li><li>Extensive knowledge and experience in all levels of claims investigation or fraud investigation and regulatory reporting requirements.</li><li>Knowledge of anti-fraud analytics programs as it relates to fraud prevention and identification.</li><li>Thorough understanding of investigative tools and techniques to guide and coach special investigators.</li><li>Demonstrated ability to build and maintain collaborative relationships with internal and external partners and business areas.</li><li>Demonstrated management skills and the ability to demonstrate monthly productivity and cycle time outcomes from investigations assigned to the SIU team.</li><li>Ability to prepare and present training sessions and case outcomes.</li><li>Demonstrated experience facilitating and managing projects and teams.</li></ul><b>What sets you apart:</b><ul><li>Demonstrated expertise in process design, risk assessment, and implementation of internal controls to mitigate fraud and other risks.</li><li>4+ years of progressive experience within a Special Investigations Unit (SIU), with a proven track record in process ownership and/or leadership roles.</li><li>Direct experience handling or managing investigations related to internal fraud, including developing investigative strategies and implementing preventative measures.</li><li>Proven ability to create engaging training content and deliver compelling presentations to diverse audiences, including investigators, management, and other stakeholders.</li><li>Exceptional business acumen and communication skills, with the ability to effectively articulate complex issues, identify gaps and opportunities within the SIU, and present recommendations to stakeholders across the organization in a clear and persuasive manner.</li><li>US military experience through military service or a military spouse/domestic partner</li></ul><p><b>Compensation range: </b>The salary range for this position is: $114,080 - $218,030<b>.</b></p><p><b>USAA does not provide visa sponsorship for this role. Please do not apply for this role if at any time (now or in the future) you will need immigration support (i.e., H-1B, TN, STEM OPT Training Plans, etc.). </b></p><p><b> Compensation: </b> USAA has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location. </p><p> </p><p> Employees may be eligible for pay incentives based on overall corporate and individual performance and at the discretion of the USAA Board of Directors. </p><p> The above description reflects the details considered necessary to describe the principal functions of the job and should not be construed as a detailed description of all the work requirements that may be performed in the job. </p><p> </p><p><b> Benefits: </b> At USAA our employees enjoy best-in-class benefits to support their physical, financial, and emotional wellness. These benefits include comprehensive medical, dental and vision plans, 401(k), pension, life insurance, parental benefits, adoption assistance, paid time off program with paid holidays plus 16 paid volunteer hours, and various wellness programs. Additionally, our career path planning and continuing education assists employees with their professional goals. </p><p> </p><p> For more details on our outstanding benefits, visit our benefits page on </p><p> Applications for this position are accepted on an ongoing basis, this posting will remain open until the position is filled. Thus, interested candidates are encouraged to apply the same day they view this posting. </p><p> </p><p> USAA is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. </p>

Manager, Special Investigations Unit (SIU) - P&C

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Special Investigations Investigator, Consultant

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Special Unit Prosecutor- Financial Crimes

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Manager, Special Investigations Unit (SIU) - P&C

Manager, Special Investigations Unit (SIU) - P&C

Manager, Special Investigations Unit (SIU) - P&C