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 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 Plan’s 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 IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

EDUCATION & 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
• Bachelor’s 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
  Start your journey towards a thriving future with IEHP and apply TODAY

Please refer the Job description for details