Lead Investigator - 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!

The Lead Investigator - Special Investigations Unit (SIU) (Lead Investigator) is responsible for investigating and resolving high complexity allegations of healthcare Fraud, Waste and Abuse (FWA) by medical professional, facilities, and members. This position researches, gathers, and analyzes data to identify trends, patterns, aberrancies, and outliers in provider billing behavior. The incumbent serves as a subject matter expert for other investigators. The Lead Investigator works collaboratively within the Plan to ensure the proper oversight of IEHP’s FWA Programs. The Lead Investigator is responsible to demonstrate IEHP’s commitment to prevent, detect, and correct identified issues of potential or actual FWA in the healthcare environment to ensure compliance with the requirements set forth by the Centers for Medicare and Medicaid Services (CMS), the United States Health and Human Services Office of the Inspector General (HHS-OIG), the California Department of Managed Health Care (DMHC), and the California Department of Health Care Services (DHCS).

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. Lead strategic fact-driven investigative projects including business process review, execution of investigative activities, and development of investigation outcome recommendations.
2. Lead end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification, develop recommendations, preparation of overpayment identifications, and closure of investigative cases.
3. Lead preparation of detailed preliminary and extensive investigation reports and referrals to Federal and/or State regulatory and/or law enforcement agencies when potential FWA is identified as required by regulatory and/or contract requirements.
4. Manage strategic investigative plan and drive investigative outcome for the team.
5. Conduct quality assurance measures of the investigative team, through auditing and oversight.
6. Identify, research, and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach.
7. Lead negotiations with recovery efforts , corrective actions, settlement agreements, and preparation of evidentiary documents for litigation.
8. Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention.
9. Proactively coordinate and collaborate with key business areas on implementing effective prevention and detection FWA-related measures and mechanisms and ensuring a comprehensive referral process of potential FWA activity to the SIU.
10. Provide guidance to the SIU Investigators on pre-investigation activities, inquiries, and projects/initiatives.
11. Lead the implementation of the FWA Program’s short and long-term goals to prevent, detect, and correct issues of fraud, waste, and abuse.
12. Perform data analysis, research, and review of claims data to identify trends, patterns, outliers, and emerging issues in healthcare fraud, waste, and abuse with fraud technology.
13. Proactively research for trending FWA schemes and alerts provided by organizations such as the National Health Care Anti-Fraud Association, HPMS fraud alerts, the CMS’ Healthcare Fraud Prevention Partnership, other anti-fraud organizations, audit vendor experiences, and state agency collaboration such as the OIG.
14. Provide guidance on risk management opportunities to avoid or prevent potential risks, non-compliance and/or violations within the Plan.
15. Perform any other duties as assigned or required to ensure Plan operations are successful.

Education & Requirements 

• Six (6) more years relevant professional experience in a health care environment, with an emphasis in fraud, waste, and abuse investigations, including Federal and State reporting requirements
• Experience in health care fraud investigation, detection, and/or healthcare related specialty including but limited to; Pharmacy, DEM, Mental Health, Behavioral Health, Hospice, Home Health, claims, or claims processing
• Bachelor’s degree from an accredited institution required (preferably in a related field)
  • Master’s degree from an accredited institution preferred
• Accredited Healthcare Fraud Investigator (AHFI) certification required

Key Qualifications

• Comprehensive knowledge of:
  • Managed Care, Medi-Cal, and Medicare programs as well as Marketplace
  • Compliance program principles and practices of managed care
  • Federal and state guidelines as well as ICD, CPT, HCPCS, coding
• Strong analytical skills with emphasis on time management and project management
• Exhibits exemplary verbal and written communication skills with thorough documentation, composing detailed investigative reports and professional internal and external correspondence
• Interpersonal and presentation skills to communicate with internal departments and external agencies
• Strong logical, analytical, critical thinking and problem-solving skills
• Proficiency in Microsoft Office programs including, but not limited to: Word, Excel, PowerPoint, Outlook, and Access
• Demonstrated proficiency in data mining and the use of data analytics to detect fraud, waste, and abuse, including the utilization of pivot tables, formulas, and trending
• Excellent interpersonal skills and business judgment
• Proven ability to:
  • Lead a Team
  • Research, comprehend, and interpret various state specific Medicaid, Federal Medicare, and ACA/Exchange laws, rules and guidelines
  • Identify, research and comprehend medical standards, healthcare authoritative sources and apply knowledge to investigative approach
  • Interact with individuals at all levels
  • Exhibit forward thinking with high ethical standards and a professional image
  • Be collaborative and team oriented
  • Share information in an organized, clear, and timely manner, both verbally and in writing
  • Take initiative, possesses excellent follow-through and persistence in locating and securing needed information
  • Manage multi-tasks and changing priorities
  • Be detail-oriented, self-motivated, able to meet tight deadlines

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)