Lead Investigator - Special Investigations Unit

IEHP • Rancho Cucamonga, CA, US

9 days ago

Job type

Full-time

Job description

Overview

The Lead Investigator - Special Investigations Unit (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 and works collaboratively within the Plan to ensure proper oversight of IEHP's FWA Programs. The Lead Investigator demonstrates IEHP's commitment to prevent, detect, and correct identified issues of potential or actual FWA in the healthcare environment to ensure compliance with CMS, HHS-OIG, DMHC, and DHCS requirements.

Key Responsibilities

Investigate and resolve high complexity allegations of healthcare Fraud, Waste and Abuse (FWA).
Research, gather, and analyze data to identify trends, patterns, aberrancies, and outliers in provider billing behavior.
Serve as a subject matter expert for other investigators.
Collaborate within the Plan to ensure proper oversight of IEHP's FWA Programs.
Demonstrate IEHP's commitment to prevent, detect, and correct identified issues of potential or actual FWA in the healthcare environment to ensure compliance with CMS, HHS-OIG, DMHC, and DHCS requirements.

Commitment to Quality

The IEHP Team is committed to incorporating IEHP's Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

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

CalPERS retirement

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 health care environment, with emphasis in fraud, waste, and abuse investigations, including Federal and State reporting requirements. Experience in health care fraud investigation, detection, and / or healthcare related specialties (i.e., Pharmacy, DEM, Mental Health, Behavioral Health, Hospice, Home Health, Claims, or Claims Processing, etc.).

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. Candidates without the current certification must obtain it within the first twenty-four (24) months of hire date.

Key Qualifications

Comprehensive in-depth 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; ICD, CPT, HCPCS coding.

Strong analytical skills with emphasis on time management and project management.

Excellent verbal and written communication skills with thorough documentation and investigative reporting.

Interpersonal and presentation skills to communicate with internal departments and external agencies.

Proficiency in Microsoft Office and data analytics tools; experience in data mining, pivot tables, formulas, and trending to detect fraud, waste, and abuse.

Ability to lead a team and collaborate, with strong ethical standards and professional image.

Compensation

Pay Range : $50.02 USD Hourly - $66.27 USD Hourly

Location : Rancho Cucamonga, CA

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Investigator • Rancho Cucamonga, CA, US