Manager, Special Investigations Unit

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Under the direction of the Director, Compliance & Risk Management, the Manager, Special Investigations Unit is responsible for leading enterprise-wide Fraud, Waste and Abuse (FWA) program initiatives. In this role, Manager, Special Investigations Unit will advance FWA program strategies to identify and address FWA. The Manager, Special Investigations Unit is responsible to develop and implement IEHP’s FWA program to identify, investigate, support the recovery, and prevention of FWA against the Health Plan. The Manager, Special Investigations Unit will ensure the work aligns with IEHP strategic regulatory and compliance initiatives and is conducted and executed effectively. The incumbent is responsible for the daily activities and functions of the Special Investigations Unit, including the management, evaluation, mentoring, and coaching of direct reports. In this capacity, the Manager, Special Investigations Unit is responsible for coordinating, implementing, monitoring, and measuring the progress of all investigations, and measuring the performance/outcomes of such efforts on a routine basis. This position is also responsible for bringing together multiple stakeholders to develop and maintain FWA risk mitigation efforts, effective internal controls, fraud prevention and detection efforts for the Health Plan.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more.

• Competitive salary.
• Hybrid schedule.
• CalPERS retirement.
• State of the art fitness center on-site.
• Medical Insurance with Dental and Vision.
• Life, short-term, and long-term disability options
• Career advancement opportunities and professional development.
• Wellness programs that promote a healthy work-life balance.
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

1. Develop and manage an effective Fraud, Waste, and Abuse (FWA) program in accordance with applicable laws, regulations, contractual requirements, and other guidance.
2. Manage and lead a team of professionals responsible for identification, investigation, medical review, recoveries, and prevention of FWA to protect the Plan from fraudulent, abusive, and wasteful schemes throughout the administration and delivery of Medi-Cal, Medicare, and Covered California benefits.
3. Utilize investigative techniques, tools, data mining, and analytics to identify FWA trends, patterns, and minimize risk of loss due to fraudulent and/or abusive actions by Providers, Members, Vendors, Contractors, and Associates through an effective FWA detection program.
4. Lead the establishment and maintenance of effective, cross-functional, working relationships within the Plan (e.g., Claims, Grievances and Appeals, Legal, Provider Network, Financial Compliance, etc.) and an effective communication program on the importance of risk mitigation, effective internal controls, fraud prevention and detection within the Plan, Subcontracted Delegates, and Business Partners.
5. Provide recommendations for improvement opportunities or enhancement of current activities based on data-driven insights. Share data driven gaps and root cause analysis findings with key stakeholders and recommend interventions that aim to address identified FWA schemes.
6. Manage the preparation of detailed reports and presentations on investigation efforts, findings, and remediation recommendations.
7. Ensure that all regulatory and compliance reports pursuant to State and Federal requirements are accurately submitted within specified timeframes.
8. Monitor and track outcomes of investigations to ensure appropriate actions are taken and potential risks are mitigated.
9. Develop FWA training and education for Team Members, Governing Board Members, IEHP Members, Providers, Vendors, Contractors, and Associates.
10. Prioritize and manage unit workload effectively to ensure timely and accurate completion of investigations and program initiatives.
11. Support legal proceedings related to SIU investigations, including testifying in court and/or collaborating with law enforcement to prepare cases for civil or criminal actions.
12. Prepare and present data driven reports to inform Executive and Senior Leadership of the operation and progress of prevention and detection efforts, including but not limited to, reduced risks, detection of FWA trends and schemes, opportunities for interventions, and measurements of program effectiveness.
13. Serve as the subject matter expert on FWA related matters to provide guidance and assist with organizational change, compliance interpretation, and organizational support.
14. Any other duties as required ensuring Health Plan operations are successful.

Education & Requirements  

• Minimum of seven (7) years of experience in healthcare investigations in a health plan SIU environment
• Minimum of five (5) years of experience leading investigators and/or medical reviewers within the SIU environment
• Experience with data mining and analysis to detect FWA trends and schemes
• Experience in health care, Medicaid Managed Care Plans (MCPs), Medicare Advantage, Medicare Part D, Special Needs Plans (SNPs), and/or Medicare-Medicaid Plans (MMPs)
• Bachelor’s degree in healthcare, Business Administration, Criminal Justice, Health Administration, or another related field.

Key Qualifications

• Must have a valid California Driver's License
• Strong and demonstrated knowledge in the following areas:
  • SIU and investigative processes and ability to suggest process improvements that increase efficiency and productivity
  • Medical terminology CDT, CPT, HCPCS, and ICD codes
  • Business ethics, FWA, and compliance risks and the knowledge to assist with management of those risks in a dynamic managed care environment
  • Federal and State laws related to healthcare FWA. This includes a solid understanding of applicable statutes such as the False Claims Act, Anti-Kickback Statute, and Stark law
  • Principles and practices of FWA programs
  • Proactively identify areas of risk to the organization related to FWA
• Accredited Healthcare Fraud Investigator (AHFI) Certification or Certified Professional Coder (CPC) preferred. 

Start your journey towards a thriving future with IEHP and apply TODAY!

This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA)