Fraud Investigator II

Date: Sep 14, 2021

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 5859 


Position Summary/Position


Under the direction of the Manager - Special Investigations Unit, the Fraud Investigator II has experience with and performs routine and complex investigations, activities, and initiatives of moderate to complex difficulty related to the Fraud, Waste and Abuse Program. The Fraud Investigator II 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 and complex 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 Investigator III to ensure appropriate action is taken to resolve the case prior to closure. 
3. Address 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. Review the FWA Program’s policies and procedures, guidelines, practices, templates and tools and make recommendations for revisions, as identified.
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. Collaborate with internal partners on FWA intelligence and initiatives and assist with tracking and trending to identify potential fraud, waste, and abuse. 
7. Coordinate with the Compliance Department’s Auditing and Monitoring Unit as it relates to FWA issues and help implement process improvement measures to prevent, correct, and mitigate those risks in the future.  
8. Create reports and analyze data for reporting to management, the Compliance Committee and the Governing Board.
9. Assist with special projects related to the development of the FWA Program. Participate in and coordinate meetings as it relates to preventing, detecting, and correcting FWA within the Plan, including FWA Subcommittee meetings.  
10. Maintain current knowledge of relevant State and Federal FWA laws and regulations and assist with adaptation of business practices to ensure compliance.
11. Respond to internal and external inquiries and provide guidance, related to FWA issues.
12. Assist with audit preparation and participate, as needed.
13. Provide support to the Compliance Specialists with monitoring intake and initiating cases, when needed.
14. Create and update desktop procedures specific to workflows and processes relevant to the FWA Program.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


3 or more years relevant professional experience in a health care environment, specific to fraud, waste, and abuse investigations, including state and federal reporting requirements.

Preferred Experience

Education Qualifications


Bachelor’s degree from an accredited institution in a related field required.

Preferred Education

Professional Certification


Professional certifications such as Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), or similar certification/licensure preferred.

Professional Licenses

Drivers License Required


Knowledge Requirement


Knowledge and experience of compliance principles and practices of managed care, FWA activities, medical terminology, and State and Federal regulatory requirements.

Skills Requirement


Critical thinking and sound analytical reasoning. Strong 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 and collaboratively within a team environment.  Ability to work independently, apply knowledge, and address situations appropriately with minimal guidance. Ability to manage multiple projects with competing deadlines and changing priorities.

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


Minimal physical activity; may include standing, walking, sitting lifting, and pushing and carrying up to 25 lbs.

Physical Requirements


Starting Salary: $57,948.80  - $73,860.80  

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