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 IEHPs FWA Programs. The Lead Investigator is responsible to demonstrate IEHPs 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 * Bachelors degree from an accredited institution required (preferably in a related field) * Masters 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 by Jobble