Lead Investigator, Special Investigations Unit

Inland Empire Health Plan; Rancho Cucamonga (CA); On-site; USD 104,000 - 138,000; Full time

Job summary

An established industry player is seeking a Lead Investigator for their Special Investigations Unit. This pivotal role involves investigating complex allegations of healthcare fraud, waste, and abuse, ensuring compliance with federal and state regulations. The ideal candidate will have extensive experience in healthcare investigations, strong analytical skills, and the ability to communicate effectively with various stakeholders. Join a forward-thinking team that values integrity and collaboration, and contribute to the mission of preventing and addressing fraud in the healthcare sector. This opportunity offers a hybrid work schedule and competitive compensation, making it an excellent choice for professionals looking to make a significant impact.

Benefits

Competitive salary

Hybrid schedule

CalPERS retirement

On-site fitness center

Medical Insurance with Dental and Vision

Life and disability insurance options

Career advancement opportunities

Wellness programs

Flexible Spending Account

Paid life insurance for employees

Qualifications

• 6+ years of experience in healthcare fraud investigations required.
• AHFI certification is mandatory for this role.

Responsibilities

• Investigate and resolve complex healthcare fraud allegations.
• Analyze data to identify trends in provider billing behavior.

Skills

Analytical Skills

Communication Skills

Project Management

Problem-Solving Skills

Interpersonal Skills

Education

Bachelor's degree

Master's degree

Tools

Microsoft Office

Data Analytics

Job description

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 professionals, 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 for demonstrating 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

• 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.
• 457(b) option with a contribution match.
• Paid life insurance for employees.
• Pet care insurance.

Education & Requirements

• Six (6) or more years of relevant professional experience in a healthcare environment, with an emphasis on fraud, waste, and abuse investigations, including Federal and State reporting requirements.
• Experience in healthcare fraud investigation, detection, and/or healthcare-related specialty including but not 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, possess 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