Lead Investigator, Special Investigations Unit

California Jobs; Rancho Cucamonga (CA); Hybrid; USD 104,000 - 138,000; Full time

Job summary

A leading healthcare organization is seeking a Lead Investigator for its Special Investigations Unit. This role is critical for investigating healthcare fraud and ensuring compliance with federal and state regulations. The ideal candidate will possess strong analytical and communication skills, a Bachelor's degree, and relevant experience in healthcare fraud investigations. The position offers competitive pay, a hybrid work schedule, and substantial professional development opportunities.

Benefits

Hybrid schedule

CalPERS retirement

State of the art fitness center on-site

Medical Insurance with Dental and Vision

Career advancement opportunities

Qualifications

• 6+ years experience in healthcare fraud investigations required.
• Experience in Federal and State reporting requirements.
• Master's degree preferred.

Responsibilities

• Investigate high complexity allegations of healthcare fraud.
• Analyze data to identify trends and patterns.
• Collaborate within the team to ensure oversight of FWA programs.

Skills

Analytical Skills

Communication Skills

Problem-Solving Skills

Data Analytics

Education

Bachelor's Degree

Master's Degree

AHFI Certification

Tools

Microsoft Office

Job description

Lead Investigator, Special Investigations Unit

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).

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

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 !

Pay Range
$104,041.60 USD Annually - $137,841.60 USD Annually

Job Type: Full-time

Pay: $104,041.60 - $137,841.60 per year

Schedule:
8 hour shift
Day shift
Monday to Friday

Application Question(s):
Do you have comprehensive knowledge of managed care, medi-cal, and medicare programs?
Do you have experience leading healthcare investigations?
This position is on a hybrid work schedule. (Mon & Fri - remote, Tues - Thurs onsite in Rancho Cucamonga, CA). Would you have any complications with this schedule?

Education:
Bachelor's (Required)

Experience:
FWA investigation in healthcare: 6 years (Required)

License/Certification:
(AHFI) certification (Required)

Work Location: Hybrid remote in Rancho Cucamonga, CA 91730

About the company

Notice

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