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Fraud Investigator I

Date: Jun 11, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 4557 


Position Summary/Position


Under the direction of the Manager – Special Investigations Unit, the Fraud Investigator I has general knowledge and performs routine investigations, activities, and initiatives of moderate difficulty related to the Fraud, Waste and Abuse Program. The Fraud Investigator I is responsible to proactively prevent, detect, and correct identified issues of fraud, waste, and abuse in the health care environment, including reporting to State and/or Federal regulatory agencies, while monitoring and maintaining a framework 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).  

Major Functions (Duties and Responsibilities)


1. Participate in the day-to-day operations of the Fraud, Waste, and Abuse (FWA) Program to meet Plan, department, and unit objectives.
2. Investigate routine FWA allegations in accordance with established procedures, efficiently and effectively, and ensure the quality and accuracy of the work product, including research, evidence gathering, interviewing, reviewing documents and analysis of whether a FWA allegation is substantiated and requires regulatory reporting.  Coordinate with Fraud Investigators II and III to ensure appropriate action is taken to resolve the case prior to case closure.
3. Assist with addressing the FWA Program’s short and long-term goals, as developed by Management, to prevent, detect, and correct issues of fraud, waste, and abuse.
4. Comprehend the FWA Program’s policies and procedures, guidelines, practices, templates and tools and use the tools to conduct investigative work.
5. Identify potential risks, non-compliance and/or alleged violations within the Plan or with external partners and issue root cause analysis/corrective action plans, as appropriate.
6. Assist with creating reports and analyzing data for reporting to management, the Compliance Committee and the Governing Board.
7. Contribute to special projects related to the development of the FWA Program. Attend and assist with meetings as it relates to preventing, detecting, and correcting FWA within the Plan, including FWA Subcommittee meetings.
8. Maintain current knowledge of relevant State and Federal FWA laws and regulations. 
9. Assist with responding to internal and external inquiries and provide guidance, related to FWA issues.
10. Assist with audit preparation, as needed.
11. Mentor and provide support to the Compliance Specialists.
12. Create and update desktop procedures specific to workflows and processes relevant to the FWA Program.

Supervisory Responsibilities
Leading: Self
Experience Qualifications


2 or more years of relevant professional experience in a health care environment.

Preferred Experience


Experience in fraud, waste and abuse investigations, medical billing, pharmacy claims, or claims processing preferred.

Education Qualifications


Bachelor’s degree from an accredited institution required.


Significant experience may be considered in lieu of degree: In lieu of a degree, a minimum of 6 years of relevant work experience is required.

Preferred Education
Professional Certification
Professional Licenses
Drivers License Required
Knowledge Requirement


Compliance principles and practices of managed care, FWA activities and medical terminology. 

Skills Requirement


Interpersonal and presentation skills to communicate with internal departments and external agencies. Effective communication skills; verbal and written. Strong organizational skills and attention to detail. Good computer skills and proficiency in Microsoft Office programs including, but not limited to: Word; Excel; PowerPoint; Outlook; and Access.

Abilities Requirement


Ability to work independently with minimal direction on recurring tasks. Work collaboratively within a team environment. Manage projects with competing deadlines and changing priorities. Critical thinking and sound analytical reasoning.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions
Physical Requirements
Hearing: One-on-One - FREQUENTLY
Hearing: Over the Telephone/Cell Phone - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Communicate: Verbally engage with customer base - FREQUENTLY
Communicate: Give instructions, advise, warn, instruct - FREQUENTLY
Near Visual Acuity - FREQUENTLY
Gross Manipulation - FREQUENTLY
Keyboarding: Traditional - CONSTANTLY
Keyboarding: 10-Key - FREQUENTLY
Use of computer mouse - CONSTANTLY
Develop and maintain positive work relationships - FREQUENTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Other contacts: public exchange - FREQUENTLY
Decision-making - FREQUENTLY
Rapid Pace of work - FREQUENTLY
Understand and follow direction - CONSTANTLY
Regular and reliable attendance - CONSTANTLY


Starting Salary: $50,835.20  - $64,792.00  

Pay rate will commensurate with experience


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. And our mission and core values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and Make a Difference with us! IEHP offers a Competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and retirement plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles