SIU Investigator I

Blue Cross Blue Shield of Arizona

. Prevent, detect, and deter fraud, waste, and abuse involving Commercial, Government, FEP, Medicare, and Part D programs .

Posted 9/21/2026full-timePhoenix • Arizona • United StatesJuniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare fraud investigations, data mining, and analysis, with strong analytical and communication skills. Proficient in managing complex cases and maintaining confidentiality while adhering to relevant laws and regulations.

Highest-signal resume keywords

Healthcare Fraud InvestigationsData Mining And AnalysisClaims Processing SystemsAnalytical SoftwareMedical Coding

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisTrend AnalysisClaims CodingReimbursement MethodologiesInvestigative ReportingDesktop And On-Site AuditsSurveillance TechniquesInterviewing SkillsCase ManagementTechnical Guidance

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationNegotiation SkillsCritical ThinkingOrganizational Skills

Tools & Technologies

Word Processing SoftwareSpreadsheet SoftwareDatabase SoftwareClaims Processing SystemsSocial Media Research Tools

Certifications & Qualifications

AHFICFECPC

Industry Keywords

Fraud PreventionFraud DetectionFraud Waste And AbuseHealthcare AdministrationInsurance Fraud Regulations

About the role

Key responsibilities & impact

Prevent, detect, and deter fraud, waste, and abuse involving Commercial, Government, FEP, Medicare, and Part D programs
Support Special Investigations Unit day-to-day operations, including investigations, analysis, management, and special projects
Triage referrals and assess appropriate disposition
Research and investigate allegations of fraud, waste, and abuse
Use claims-processing systems, medical coverage guidelines, payment policies, benefits, and provider contracts
Apply data-mining techniques, statistical data analysis, and analytical software to identify potential fraud, waste, and abuse
Develop leads and cases from fraud alerts and government and private sources
Prepare summary reports, corrective action plans, and investigative findings
Escalate high-risk tips, cases, and related issues to management
Conduct desktop and on-site medical-record audits, surveillance, undercover work, and suspect and witness interviews
Prepare cases for referral to law-enforcement officials
Testify and provide depositions as an expert witness
Maintain chain of custody and document every stage of investigations
Create, update, and follow operating procedures, policies, confidentiality requirements, and security guidelines
Develop materials and assist with fraud, waste, and abuse training
Attend annual seminars and webinars and participate in corporate task teams
At higher levels, conduct complex investigations, develop queries, evaluate data integrity, provide technical guidance, manage case-tracking systems, design trend-analysis reports, support reporting requirements, coordinate external post-payment claims reviews, and perform quality audits

Requirements

What you’ll need

One year of experience in healthcare-related fraud investigations and/or data mining and analysis
High school diploma or GED in a general field of study
Intermediate personal-computer proficiency for Levels 1 and 2; advanced proficiency for Level 3
Intermediate skill with word-processing, spreadsheet, and database software for Levels 1 and 2; advanced skill for Level 3
Intermediate skill using office equipment
Basic knowledge of laws and regulations pertaining to insurance fraud and judicial processes related to fraud prosecutions
Strong ability to use social media and public websites to research allegations
Ability to maintain confidentiality and privacy
Ability to prioritize, organize, and independently manage work
Ability to manage multiple complex tips, cases, reports, projects, and tasks
Analytical, data-analysis, and trend-analysis skills
Excellent verbal and written communication, negotiation, and interviewing skills
Knowledge of relevant technology, claims coding, reimbursement methodologies, company products and policies, and relevant fraud schemes
Critical-listening and critical-thinking skills
Preferred: three to five years of experience in healthcare-related fraud investigations, data mining and analysis, and/or complex projects
Preferred: experience with medical coding and/or billing
Preferred: strong understanding of health insurance reimbursement methodologies and current medical claim coding requirements
Preferred: bachelor’s degree in business, healthcare administration, accounting, nursing, criminal justice, or a related field
Preferred certifications: AHFI, CFE, CPC, or other certificates, designations, and/or advanced training in healthcare fraud and abuse investigations

Benefits

Comp & perks

Hybrid work flexibility through AZ Blue’s Workability workforce strategy
Health insurance products and services
Full-time schedule of at least 40 hours per week
Professional development through annual seminars and webinars
Participation in fraud, waste, and abuse training and corporate task teams