Lead Investigator - Special Investigations Unit

Inland Empire Health Plans; Rancho Cucamonga (CA); Hybrid; USD 75,000 - 115,000; Full time

Job summary

Join a forward-thinking organization dedicated to healing and inspiring the human spirit! As a Lead Investigator in the Special Investigations Unit, you will play a pivotal role in combating healthcare fraud, waste, and abuse. This position requires a keen analytical mind and a commitment to compliance, ensuring that the organization adheres to the highest standards set by regulatory bodies. You will work within a collaborative environment, utilizing your expertise to lead investigations and guide fellow team members. If you are passionate about making a difference in healthcare and have the skills to drive change, this is the opportunity for you!

Benefits

Competitive salary

Hybrid schedule

CalPERS retirement

On-site fitness center

Medical Insurance with Dental and Vision

Life and disability options

Career advancement opportunities

Wellness programs

Flexible Spending Account

Paid life insurance

Qualifications

• 6+ years in healthcare fraud investigations with federal/state reporting.
• Strong knowledge of managed care and compliance principles.

Responsibilities

• Investigate and resolve complex healthcare fraud allegations.
• Collaborate with teams to ensure compliance with FWA programs.

Skills

Analytical Skills

Verbal Communication

Written Communication

Problem-Solving

Project Management

Education

Bachelor's Degree

Master's Degree

AHFI Certification

Tools

Microsoft Office

Data Analytics Tools

Job description

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

Education & Requirements

• Six (6) or 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 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, 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!