Special Investigations Unit - Investigator II

The Special Investigations Unit Investigator II investigates and analyzes incidents of suspected fraud, waste, and abuse in accordance with regulatory requirements. The Special Investigations Unit Investigator II is responsible for conducting full investigations to proactively prevent, detect, and correct suspected and identified issues of fraud, waste, and abuse in the health care environment, including reporting to State and / or Federal regulatory agencies. The incumbent makes potential fraud, waste, or abuse determinations by utilizing a variety of sources including data analytics to detect unusual billing. The Special Investigations Unit Investigator II conducts monitoring and supports the Plans Fraud, Waste and Abuse Program (FWA) to ensure compliance with State and / or 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 IEHPs Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

• Key Duties
• Identify, investigate, and analyze instances of alleged Fraud, Waste and Abuse (FWA) in accordance with regulatory requirements.
• Develop leads presented to the SIU to assess and determine whether potential FWA is corroborated by evidence.
• Conduct both preliminary assessments of FWA allegations, and end to end full investigations, including but not limited to witness interviews, background checks, data analytics to identify outlier billing behavior, contract and program regulation research, provider and member education, findings identification, develop recommendations, preparation of overpayment identifications, and closure of investigative cases.
• Prepare detailed preliminary and extensive investigation referrals to Federal and / or State regulatory and / or law enforcement agencies when potential FWA is identified as required by regulatory and / or contract requirements.
• Render provider education on appropriate practices (e.g., coding) as appropriate based on national or local guidelines, contractual, and / or regulatory requirements.
• Prepare audit results letters to providers when overpayments are identified.
• Prepare and conduct in-depth complex interviews relevant to investigative plan.
• Present, support, and defend investigative research to seek approval for formal corrective actions.
• Establish and maintain relationships with Federal and State law enforcement agencies, task force members, other company SIU staff and external contacts involved in fraud investigation, detection and prevention.
• Support regulatory communication requests as required, including providing claims data analysis, medical policy guidelines, and other documents / information.
• Support the FWA Programs short and long-term goals, as developed by Management, to prevent, detect, and correct issues of fraud, waste, and abuse.
• Review the FWA Programs policies and procedures, guidelines, practices, templates, and tools and make recommendations for revisions, as identified.
• 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.
• Collaborate with internal partners on FWA intelligence and initiatives and assist with tracking and trending to identify potential fraud, waste, and abuse.
• Coordinate with Compliance Auditors as it relates to FWA issues and help implement process improvement measures to prevent, correct, and mitigate those risks in the future.
• Perform any other duties as assigned to ensure Plan operations are successful.
• Experience
• & Requirements
• Four (4) 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 limited to; Pharmacy, DEM, Mental Health, Behavioral Health, Hospice, Home Health, claims, or claims processing preferred
• Bachelors degree from an accredited institution
• 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
• Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or similar certification / licensure preferred
• Key Qualifications
• Strong knowledge of Managed Care, Medi-Cal, and Medicare programs as well as Marketplace
• Compliance program principles and practices of managed care. Knowledge of federal and state guidelines as well as ICD, CPT, HCPCS, coding
• Excellent 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
• 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 data mining 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 and collaboratively within a team environment.
• Apply knowledge, and address situations appropriately with minimal guidance
• Manage multiple projects with competing deadlines and changing priorities
• 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
• Minimal physical activity; may include standing, walking, sitting lifting, and pushing and carrying up to 25 lbs
• This Position is Hybrid schedule, with 3 onsite days at our Main Campus in Rancho Cucamonga.

Job Type : Full-time

Pay : $80,059.20 - $106,059.20 per year

Benefits :

• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Loan forgiveness
• Professional development assistance
• Retirement plan
• Tuition reimbursement
• Vision insurance

Work Location : Hybrid remote in Rancho Cucamonga, CA 91730

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