Manager, Special Investigations Unit Medical Record Audit

Inland Empire Health Plan•Rancho Cucamonga, CA

11h•$118,602 - $157,144•Hybrid

About The Position

Under the direction of the Vice President of Compliance, and in close partnership with the Special Investigations Unit (SIU) Manager, the SIU Medical Record Audit Manager provides leadership and strategic direction for IEHP’s prepayment and post-payment medical record audit functions within the Fraud, Waste, and Abuse (FWA) framework. This role holds primary authority over medical record audit operations and is accountable for the accuracy, consistency and defensibility of every audit determination issued by the unit. The SIU Medical Record Audit Manager oversees and develops a team of Medical Record Auditors, directing complex coding and documentation audits of medical records and claims to determine the accuracy, appropriateness, and compliance of billed services under federal and state requirements applicable to each line of business. The incumbent holds final determination authority on coding, billing, and documentation-sufficiency findings, and is responsible for generating measurable financial impact through overpayment identification, cost ‑ avoidance recommendations, prepayment intervention, and remediation of the payment vulnerabilities that audits surface. In addition to daily leadership of staff, the SIU Medical Record Audit Manager designs, implements, and continuously improves review methodologies, performance metrics, quality assurance protocols, and reporting frameworks that strengthen IEHP’s program integrity posture and withstand regulatory, provider, and judicial challenge. The incumbent ensures medical record audit operations are executed with precision, consistency, and alignment to IEHP’s strategic compliance objectives, while proactively identifying risks, monitoring trends, and evaluating the effectiveness and outcomes of all medical record audit activities on an ongoing basis. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Requirements

Minimum of seven (7) years of progressively responsible experience in medical record audits and claims review, coding audit, or related healthcare payment integrity of which a minimum of three (3) to five (5) years must be in a lead or management capacity overseeing medical record review, coding audit, or SIU/FWA activities required
Medicare and Medicaid managed care experience required, including working knowledge of federal and state Medicaid coverage, billing, and documentation requirements
Demonstrated ownership of prepayment review or claim edit–driven review operations, including criteria development and turnaround management
Demonstrated experience defending review determinations through provider dispute, appeal, regulatory audit, or litigation support
Experience with medical record audits supporting statistical sampling and extrapolated recovery
Bachelor’s degree in Medical Billing/Medical Coding, Nursing, Healthcare Administration, Health Information Management, or related field from an accredited institution required
Advanced degree (e.g., MBA, MHA, MPH, MSN, MS ‑ HIM) that strengthens program leadership, analytics, or operational management capabilities
Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS)
Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Certified in Healthcare Compliance (CHC) or Certified Professional Compliance Officer (CPCO), and relevant analytics/process credentials (e.g., Lean/Six Sigma, Prosci)
Active RN or other clinical licensure (e.g., NP, PA) or equivalent advanced clinical credential
Deep knowledge of medical coding and billing practices; thorough understanding of ICD, CPT, HCPCS, DRG, revenue codes, NDCs, and associated guidelines
Strong understanding of Medi Cal and Medicare regulatory framework and managed care in California; familiarity with SIU operations, investigative processes, and legal evidentiary standards in healthcare
Familiarity with anti fraud solutions, claims data environments, and analytic tools used to identify outliers and patterns
Claim payment timeliness and provider dispute resolution requirements applicable to prepayment review, including California Health & Safety Code §§ 1371 and 1371.1 and applicable Medicare timeliness standards
CMS program integrity guidance, including the Program Integrity Manual, and OIG guidance on FWA typologies
NCCI, MUE, and modifier application rules, and the distinction between Medicare and Medi-Cal edit and coverage authority
Leadership & Influence: Ability to lead teams, set standards, and influence cross-functional stakeholders; skilled in negotiation and conflict resolution
Analytical Rigor: Advanced capability to interpret and analyze healthcare data and medical records; formulate defensible findings; synthesize complex information into executive level insights
Communication: Exceptional written and verbal skills; ability to articulate medical record audit findings clearly and thoroughly, and present to leadership, regulators, and law enforcement
Operational Excellence: Strong organizational and time management abilities; adept at building QA frameworks, dashboards, and performance metrics
Technology Proficiency: Above average proficiency in Excel, Word, PowerPoint, and antifraud/data platforms; adaptable to new systems and workflows.
Project/Change Management: Ability to manage multiple priorities and drive process improvement initiatives end to end
Exercise independent judgment and final decision ‑ making authority on complex medical record audit matters
Maintain strict confidentiality; operate with integrity and discretion in sensitive investigative activities
Manage multiple projects with competing deadlines and changing priorities.
Develop, analyze, and apply applicable organizational policies and programs effectively
Possess attention to detail & commitment to delivering high-quality work products.
Ability to write determinations that state the finding, the controlling authority, and the specific documentation deficiency, at a standard that survives provider appeal and regulatory audit without supplementation
Ability to distinguish coding or documentation finding from a clinical necessity question and to route each to the correct owner
Ability to identify and escalate indicators of fraud, entity structure irregularity, or fabrication encountered during review, without incorporating those theories into provider-facing determinations
Automobile travel within California or other states for business travel/function

Nice To Haves

Valid California Driver’s License preferred

Responsibilities

Provide strategic and operational leadership for SIU’s prepayment and post payment medical record audit program.
Establish and maintain audit strategies, standards, SOPs, KPIs, and QA methodologies aligned with Compliance and program integrity objectives.
Develop operational dashboards to monitor turnaround, work in process aging, determination quality, corrective action timeliness, and appeal uphold rates.
Oversee audit documentation quality for regulatory submissions and support formal responses to DHCS, DMHC, CMS, and law enforcement entities.
Ensure team adherence to ethical conduct, confidentiality requirements, and audit ready file maintenance.
Lead end to end prepayment medical record review operations, including documented criteria for placing and releasing providers, turnaround compliance within claims payment timeframes, yield optimization, false positive monitoring, inventory aging, and scheduled reassessment and exit decisions.
Identify payment vulnerabilities surfaced through prepayment reviews and route systemic findings for corrective remediation.
Ensure prepayment activities produce measurable cost avoidance impact.
Direct and review post payment medical record audits, claim reviews, and documentation sufficiency determinations.
Serve as the final determination authority on coding, billing, and regulatory compliance findings, ensuring every determination is supported by controlling authority for the applicable line of business.
Maintain audit accuracy and defensibility in preparation for provider appeals, regulatory review, and potential judicial challenge.
Ensure audit outcomes support timely overpayment identification, fraud referral reporting, and financial recovery expectations.
Implement and oversee a comprehensive QA program including internal reviews, vendor oversight, random sampling, error typology tracking, and corrective action development.
Lead SOP refinement, criteria clarification, retraining, and process improvement initiatives in response to identified variances.
Provide technical guidance to support probe reviews, statistically valid samples, extrapolated findings, and review integrity.
Partner with SIU Investigators on sample design, stratification methodology, and interpretation of sample results.
Lead audit determination defense across provider disputes, appeals, regulatory audits, and legal proceedings.
Conduct or direct reconsideration reviews, ensuring determinations meet defensibility standards and uphold the correct application of regulatory and coding authority.
Deliver audit findings to IEHP leadership, Compliance, regulators, law enforcement, and legal entities as needed.
Maintain a strong sustain rate across all challenged determinations.
Ensure timely delivery of required regulatory reports, fraud referrals, overpayment notifications, and committee level audit metrics.
Produce trend analyses, cost avoidance reporting, and actionable insights for Compliance leadership.
Draft, maintain, and refine pre and post payment medical record audit policies and procedures.
Identify operational, configuration, and documentation vulnerabilities surfaced through audits and route findings to appropriate owners.
Recruit, train, mentor, and evaluate Medical Record Auditors, maintain succession plans, develop technical competencies, and foster a high performing, mission aligned team culture.
Hire, train, and manage support staff, while monitoring and evaluating outcomes.
Conduct performance reviews of each team Member within IEHP guidelines.
Perform any other duties as required to ensure Health Plan operations and department business needs are successful.