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SIU Investigator II – Provider Claims (FWA)

Alura Workforce Solutions

Rancho Cucamonga, CA

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JOB DETAILS
SKILLS
Analysis Skills, Behavioral Health, Billing, Certified Financial Examiner (CFE), Certified Professional Coder (CPC), Claims Processing, Coding Standards, Communication Skills, Consumer Assessment of Healthcare Providers and Systems (CAHPS), Contract Law, Current Procedural Terminology (CPT), Data Analysis, Data Mining, Detail Oriented, Documentation, Federal Government, Fitness, Fraud Investigation, Health Maintenance Organization (HMO), Health Plan, Healthcare, Healthcare Common Procedure Coding System (HCPCS), Healthcare Effectiveness Data and Information Set (HEDIS), Home Care, Hospice Care, International Classification of Diseases (ICD), Interpersonal Skills, Investigative Reports, Maintain Compliance, Managed Care, Medi-Cal, Medical Protocols, Medical Research, Medicare, Microsoft Access Database, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft PowerPoint, Microsoft Word, Multitasking, National Committee for Quality Assurance (NCQA), Organizational Skills, Pharmacy, Pivot Tables, Preferred Provider Organization (PPO), Presentation/Verbal Skills, Problem Solving Skills, Psychiatry and Mental Health, Regulations, Regulatory Compliance, Regulatory Reports, Research Skills, Time Management, Writing Skills
LOCATION
Rancho Cucamonga, CA
POSTED
30+ days ago
Special Investigations Unit Investigator II
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
Knowledge, skills, and abilities
  • 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
Required qualifications
  • 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)
Preferred experience and credentials
  • 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
Additional Information
  • Full-Time Direct Placement
  • Hybrid Schedule: Hybrid schedule (onsite Tuesday - Thursday)
  • (3) Flex Remote Days ea. Quarter. 
Perks and benefits
  • Competitive salary
  • Bonus programs 
  • On-site Fitness Center
  • Career advancement and professional development opportunities 
Time Off / Holidays:
  • 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 
Healthcare: 
  • 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 
Retirement:
  • CalPERS pension retirement program
  • 457(b) option with employer contribution match up to 6% (dollar-for-dollar) with immediate vesting

About the Company

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Alura Workforce Solutions