Special Investigations Unit Director jobs in California

Special Investigations Unit Director oversees the operations for conducting thorough investigations. Develops the strategies for the cross-functional detection and elimination of fraudulent behavior. Being a Special Investigations Unit Director prepares investigative reports and analyses that pertinent to evidence obtained during investigations. May coordinate with outside sources such as law enforcement agencies, and external audit, etc. Requires a bachelor's degree. Additionally, Special Investigations Unit Director typically reports to top management. The Special Investigations Unit Director manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. To be a Special Investigations Unit Director typically requires 5 years experience in the related area as an individual contributor. 1 - 3 years supervisory experience may be required. Extensive knowledge of the function and department processes. (Copyright 2024 Salary.com)

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Special Investigations Unit Medical Reviewer
  • IEHP
  • Rancho Cucamonga, CA FULL_TIME
  • What you can expect!

    Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

    Under general supervision, the Special Investigations Unit Medical Reviewer (SIU Medical Reviewer) performs reviews of medical records and healthcare claims to substantiate or refute the accuracy and compliance with federal and state regulations and contractual requirements of codes billed to identify coding errors and billing discrepancies in relation to incidents of suspected healthcare fraud, waste, and abuse (FWA) reported to IEHP’s Compliance Special Investigations Unit (SIU).

    Key Responsibilities:

    • Perform reviews of medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations.
    • Understand, interpret, analyze, and make determinations concerning use of CDT, CPT, ICD, DRG, REV and HCPCS coding as it relates to potential healthcare FWA schemes.
    • Conduct research relevant to issues under review.
    • Prepare and submit detailed reports with the results of medical reviews, including corrective action recommendations to investigators. Recommendations may include determinations to deny, recover on overpaid claims, risk mitigation strategies, create internal process improvements or provide education to subjects under review.
    • Apply knowledge of healthcare coding conventions, policies, and other areas of vulnerability.
    • Support/participate in provider calls and reinforce medical review findings and provider education.
    • Presents findings to leadership, regulators and law enforcement and assist in legal proceedings, as appropriate.
    • Maintain knowledge of new and relevant regulations, standards, and coding guidelines.
    • Identify inefficiencies in policies or processes and recommend improvements.


    10 . Maintain confidentiality and discretion in all investigative activities.

    • Support special projects and other duties as assigned.


    Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

    Perks

    IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.

    • CalPERS retirement
    • 457(b) option with a contribution match
    • Generous paid time off- vacation, holidays, sick
    • State of the art fitness center on-site
    • Medical Insurance with Dental and Vision
    • Paid life insurance for employees with additional options
    • Short-term, and long-term disability options
    • Pet care insurance
    • Flexible Spending Account – Health Care/Childcare
    • Wellness programs that promote a healthy work-life balance
    • Career advancement opportunities and professional development
    • Competitive salary with annual merit increase
    • Team bonus opportunities


    Education & Experience

    • A minimum of two (2) years of experience performing medical reviews of medical records and claims in a healthcare setting
    • Bachelor’s degree in medical billing or medical coding, nursing, healthcare administration, or other related field from an accredited institution required
    • Certified Professional Coder (CPC) required
    • One of the following licenses preferred
    • Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians
    • Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN


    Key Qualifications

    • Strong verbal and written communication, interpersonal skills, critical problem-solving skills, and attention to detail
    • Above average proficiency in the use of technology applications, particularly Excel, Word, and others as necessary


    Start your journey towards a thriving future with IEHP and apply TODAY!
  • Just Posted

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Special Investigations Unit Medical Reviewer
  • Inland Empire Health Plan
  • Rancho Cucamonga, CA FULL_TIME
  • Overview What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experien...
  • 21 Days Ago

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Director of Special Investigations (Workers Compensation)
  • Berkshire Hathaway Homestate Companies
  • Sacramento, CA OTHER
  • WHO WE ARE Berkshire Hathaway Homestate Companies is dedicated to being the best workers compensation insurance company by providing compassionate care to injured workers, superior service to our cust...
  • 19 Days Ago

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Director of Special Investigations (Workers Compensation)
  • Berkshire Hathaway Homestate Companies
  • Walnut Creek, CA OTHER
  • WHO WE ARE Berkshire Hathaway Homestate Companies is dedicated to being the best workers compensation insurance company by providing compassionate care to injured workers, superior service to our cust...
  • 19 Days Ago

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Director of Special Investigations (Workers Compensation)
  • Berkshire Hathaway Homestate Companies
  • San Diego, CA OTHER
  • WHO WE ARE Berkshire Hathaway Homestate Companies is dedicated to being the best workers compensation insurance company by providing compassionate care to injured workers, superior service to our cust...
  • 19 Days Ago

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Director of Special Investigations (Workers Compensation)
  • Berkshire Hathaway Homestate Companies
  • Sacramento, CA OTHER
  • WHO WE ARE Berkshire Hathaway Homestate Companies is dedicated to being the best workers compensation insurance company by providing compassionate care to injured workers, superior service to our cust...
  • 20 Days Ago

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Cash Management / FX Operations Consultant
  • Phaxis
  • Jersey City, NJ
  • A global Financial Firm is looking to hire an experienced Cash Management / FX Ops Consultant to join their team in Jers...
  • 6/10/2024 12:00:00 AM

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Cash Management
  • Confidential
  • Jersey City, NJ
  • Cash Management - AVP Work Schedule: Hybrid (on-site 2 days a week) SUMMARY: Support and approves MGeB, Test Key and oth...
  • 6/10/2024 12:00:00 AM

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Employee Relations Director
  • Robert Half
  • Atlanta, GA
  • Robert Half HR Solutions is currently sourcing for a Contract Employee Relations/Investigation Director for our retail c...
  • 6/9/2024 12:00:00 AM

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Cash Management Associate
  • Phyton Talent Advisors
  • Jersey City, NJ
  • Our Client, a Global Investment Bank, is seeking a Cash Management Associate in their Jersey City, NJ location. Responsi...
  • 6/9/2024 12:00:00 AM

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RN Administrative Coordinator Relief- Moses Cone
  • Cone Health
  • Greensboro, NC
  • Overview: Accountable for operational throughput with patients, families, nursing staff and physicians, between departme...
  • 6/9/2024 12:00:00 AM

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Research Regulatory Specialist
  • Georgia Clinical Research LLC
  • Lawrenceville, GA
  • Job Description Job Description Works with the Research Director, Investigators, Study Coordinators, Sponsor Representat...
  • 6/8/2024 12:00:00 AM

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Cash Management- Back Office
  • Mizuho Bank, Ltd.
  • Jersey City, NJ
  • SUMMARY: Support and approves MGeB, Test Key and other payment request transactions for Corporate customers for Mizuho B...
  • 6/8/2024 12:00:00 AM

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Safety Director
  • SAY Group
  • SAY Group is supporting a client who is looking to hire a Safety Director. This is an exciting opportunity for someone w...
  • 6/8/2024 12:00:00 AM

California is a state in the Pacific Region of the United States. With 39.6 million residents, California is the most populous U.S. state and the third-largest by area. The state capital is Sacramento. The Greater Los Angeles Area and the San Francisco Bay Area are the nation's second and fifth most populous urban regions, with 18.7 million and 9.7 million residents respectively. Los Angeles is California's most populous city, and the country's second most populous, after New York City. California also has the nation's most populous county, Los Angeles County, and its largest county by area, S...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Special Investigations Unit Director jobs
$172,273 to $259,486

Special Investigations Unit Director in Waco, TX
The SIU will be led by two ICSS directors and experienced senior investigators, Fred Lord and Dale Sheehan.
January 04, 2020
Special Investigations Unit Director in Monroe, LA
The Special Investigations Unit (SIU) is a progressive policing project aimed at reducing violent crime on Capitol City streets.
December 25, 2019
Special Investigations Unit Director in Evansville, IN
The Unit is an agency of the Ministry of the Attorney General of Ontario and maintains a close relationship with the government of Ontario.
November 27, 2019