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.
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, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and 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 stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.
Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles