SIU Investigator II Provider Claims (FWA) 26-00016
Alura Workforce Solutions
Rancho Cucamonga, CA
JOB DETAILS
SALARY
$80,059.20–$106,059.20 Per Year
LOCATION
Rancho Cucamonga, CA
POSTED
22 days ago
SIU Investigagtor - Provider Claims (FWA)
About the role
Our client is a mission-driven health plan committed to "healing and inspiring the human spirit.” The Special Investigations Unit (SIU) Investigator II investigates and analyzes suspected fraud, waste, and abuse (FWA) in accordance with state and federal requirements. This role leads full investigations to proactively prevent, detect, and correct FWA in the health care environment, including required reporting to regulatory agencies. The Investigator II leverages multiple sources, including data analytics, to identify unusual billing patterns and support an effective FWA Program.
Key responsibilities
- Conduct full-cycle FWA investigations from intake through resolution, including evidence gathering, analysis, documentation, and case presentation
- Identify, research, and evaluate suspected fraud, waste, or abuse using claims data, billing trends, records review, and investigative leads
- Utilize data mining and analytics to detect outliers and unusual billing patterns, including pivot tables, formulas, and trending
- Develop well-supported determinations and produce thorough investigative reports and professional internal and external correspondence
- Prepare and submit required referrals and reports to appropriate state and federal agencies, as applicable
- Support ongoing monitoring activities that strengthen the organization's Fraud, Waste and Abuse Program and ensure compliance with contracts, laws, regulations, and guidance
- Partner with internal departments and external agencies to support investigations, prevention, and education efforts
- Contribute to the organization's quality program goals, including measures tied to HEDIS, CAHPS, and NCQA accreditation
- Strong knowledge of managed care, Medi-Cal, Medicare, and Marketplace programs
Knowledge of compliance program principles and managed care practices
Working knowledge of federal and state guidelines and coding standards, including ICD, CPT, and HCPCS - Excellent written and verbal communication skills with the ability to produce detailed investigative reports and professional correspondence
- Strong interpersonal and presentation skills to communicate with internal stakeholders and external agencies
- Demonstrated analytical, problem-solving, and resolution skills
Strong organizational skills and attention to detail, with the ability to manage multiple priorities and deadlines - Proficiency with Microsoft Office (Word, Excel, PowerPoint, Outlook, Access)
Proven ability to work independently and collaboratively, apply sound judgment with minimal guidance, and interpret complex Medicaid, Medicare, and ACA/Exchange requirements - Ability to research and interpret medical standards and authoritative health care sources and apply findings to investigative approach
- Four (4) or more years of relevant professional experience in a health care environment with an emphasis in FWA investigations, including federal and state reporting requirements
- Bachelor's degree from an accredited institution
In lieu of a degree, a minimum of four (4) additional years of relevant experience may be substituted (in addition to the minimum experience requirement)
- Experience in health care fraud investigation, detection, and/or a related specialty area such as Pharmacy, DEM, Mental Health, Behavioral Health, Hospice, Home Health, Claims, or Claims Processing
- One or more preferred: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or similar certification/licensure
- Full-Time Direct Placement
- Hybrid Schedule: Hybrid schedule (onsite Tuesday - Thursday)
- (3) Flex Remote Days ea. Quarter.
- Competitive salary
- Bonus programs
- On-site Fitness Center
- Career advancement and professional development opportunities
- Vacation: 18 days/year (0–4 years); 23 days/year (5–8 years); 8 days/year (9+ years)
- Holidays: 12 Paid Holidays
- Sick days: (5) Sick Days
- Medical plan options through Blue Shield (HMO, PPO, and HDHP) with low monthly premiums and Premium Delta Dental & EyeMed.
- Wellness spending account, wellness reimburesement and tuition reimbursement
- CalPERS pension retirement program
- 457(b) option with employer contribution match up to 6% (dollar-for-dollar) with immediate vesting
About the Company
A