Inland Empire Health Plan
Special Investigations Unit - Investigator II (Hybrid Work Schedule)
Inland Empire Health Plan, Rancho Cucamonga, California, United States, 91739
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.
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
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! #J-18808-Ljbffr
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.
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
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! #J-18808-Ljbffr