Lead Investigator - Special Investigations UnitIEHP • Rancho Cucamonga, CA, US
Lead Investigator - Special Investigations Unit
IEHP • Rancho Cucamonga, CA, US
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job_description.job_card.job_descriptionCompetitive 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 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. 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.
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
Education & Requirements
Key Qualifications
Compensation
Pay Range : $50.02 USD Hourly - $66.27 USD Hourly
Location : Rancho Cucamonga, CA
J-18808-Ljbffr
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Investigator • Rancho Cucamonga, CA, US
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