Special Investigations Unit Investigator I

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 Special Investigations Unit Investigator I investigates and analyzes incidents of suspected fraud, waste and abuse in accordance with regulatory requirements. The Special Investigations Unit Investigator I is responsible for partnering in the prevention, detection, investigation, reporting, and when appropriate, recoveries related to health care fraud, waste, and abuse. The incumbent collaborates with subject matter experts to identify, investigate, and correct fraudulent and/or abusive billing and coding practices. The Special Investigations Unit Investigator I supports the Plan’s Fraud, Waste and Abuse Program (FWA) to ensure compliance with State and Federal contracts, laws, regulations, and guidance 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. Conduct preliminary assessments of allegations and investigates issues pertaining to potential health care fraud, waste, or abuse by Providers or Members, including conducting assessments, research, evidence gathering, reviewing documents, and analysis.
2. Conduct data analytics to identify outliers, billing patterns and behaviors, aberrant coding, and assess risks for suspected fraud, waste, or abuse.
3. Utilize anti-fraud technology to identify new opportunities for investigation.
4. Organize and prioritize investigations, securing needed information to substantiate or refute allegations.
5. Prepare clear, concise, and complete investigative reports and integrate medical review findings, if appropriate.
6. Participate in the day-to-day operations of the Fraud, Waste, and Abuse (FWA) Program to meet Plan, department, and unit objectives.
7. Understand, interpret, analyze, and make investigative determinations concerning CPT, ICD and HCPCS coding as it relates to potential healthcare fraud schemes.
8. Coordinate with SIU Investigators to ensure appropriate action is taken to resolve the case prior to case closure.
9. Maintain cases referred to law enforcement and respond to requests for information; pursue applicable administrative actions during investigation/case development.
10. Comprehend the FWA Program’s policies and procedures, guidelines, practices, templates, and tools and use the tools to conduct investigative work.
11. Identify potential risks, non-compliance and/or alleged violations within the Plan or with external partners and issue root cause analysis/corrective action plans, as appropriate.
12. Document and maintain organized investigative case work documentation that enable collaboration with external teams in the investigation and recovery process.
13. Assist with developing reports and analyzing data for reporting to leadership, the Compliance Committee, the IEHP Governing Board, and Regulatory Agencies.
14. Assist with responding to internal and external inquiries and provide guidance, related to FWA issues.
15. Create and update desktop procedures specific to workflows and processes relevant to the FWA Program.
16. Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Education & Requirements 

• Two (2) or more years of relevant professional experience in a health care environment
  • Experience in health care fraud investigation, detection, and/or healthcare related specialty including but limited to; Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, claims, or claims processing preferred
• Bachelor’s degree from an accredited institution required
  • In lieu of the required degree, a minimum of four (4) years of additional relevant work experience is required for this position
  • This experience is in addition to the minimum years listed in the Experience Requirements above

 Key Qualifications

• Knowledge of Managed Care, Medi-Cal, and Medicare programs as well as Marketplace
• Compliance program principles and practices of managed care preferred
• Knowledge of federal and state guidelines as well as ICD, CPT, HCPCS, coding preferred
• Excellent verbal and written communication skills with thorough documentation
• Interpersonal and presentation skills to communicate with internal departments and external agencies
• Demonstrated analytical, problem solving, and resolution skills
• Strong organizational skills and attention to detail
• Proficiency in Microsoft Office programs including, but not limited to: Word, Excel, PowerPoint, Outlook, and Access
• Demonstrated proficiency in datamining and the use of data analytics to detect fraud, waste, and abuse, including the utilization of pivot tables, formulas, and trending
• Proven ability to:
• Work independently with minimal direction on recurring tasks
• Remain objective and separate facts from opinions
• Research and interpret regulatory requirements
• Work collaboratively within a team environment
• Develop realistic goals and objectives, track progress, and adapt to changing priorities

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)