Inland Empire Health Plan-posted 4 months ago
$71,572 - $93,038/Yr
Full-time • Mid Level
Rancho Cucamonga, CA

The Special Investigations Unit (SIU) Intelligence Analyst is responsible for providing proactive, data-driven intelligence to prevent and detect healthcare fraud, waste, and abuse in Medi-Cal, Medicare, and Covered California programs. This role bridges data science and investigations by conducting data mining, statistical trend analysis, and anomaly detection to validate leads and escalate high-impact patterns for formal investigation. The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

  • Perform advanced data analytics and intelligence gathering to identify emerging fraud trends, organized schemes, and high-risk providers or claims.
  • Conduct data mining and exploratory analytics to identify emerging fraud schemes, suspicious billing patterns, and provider/vendor anomalies.
  • Provide actionable intelligence, lead packages, and data visualization to SIU investigators in support of fraud, waste, and abuse (FWA) investigations.
  • Evaluate large datasets, including claims, medical records, provider enrollments, and utilization to uncover outlier behavior and systemic vulnerabilities.
  • Maintain SIU case documentation and track lead disposition to support audits and ensure regulatory readiness.
  • Build and maintain dashboards, reports, and risk detection models to identify and monitor healthcare fraud, waste, and abuse trends.
  • Prepare concise intelligence reports, presentations, and briefings for SIU leadership, Legal, Compliance, and operational teams.
  • Cross-functional collaboration with IEHP’s Business Units to validate lead data and support program improvement.
  • Perform any other duties as required to ensure Health Plan operations and department business needs are successful.
  • Bachelor’s degree in Criminal Justice, Data Science, Healthcare Administration, Statistics, Business Administration, Public Health, or a related field from an accredited institution required.
  • Minimum of three (3) years of experience in healthcare data analytics, FWA detection, or managed care compliance required.
  • Experience with SQL and Power BI required.
  • Strong knowledge of CPT/HCPCS/ICD-10 coding, billing rules, and healthcare reimbursement models.
  • Exceptional analytical, problem-solving, and organizational skills.
  • Excellent interpersonal and communication skills, capable of working effectively across various departments and with external partners.
  • Strong judgment and risk assessment capabilities.
  • Ability to interpret complex claims data and identify FWA red flags.
  • Proven ability to work independently and as part of a team in a high-stakes environment.
  • Ability to manage multiple projects with competing deadlines.
  • Detail-oriented.
  • Strong commitment to integrity and ethical decision-making.
  • Certified Professional Coder (CPC), or similar certification related to healthcare fraud, coding, and billing is preferred.
  • Advanced SAS Programmer certification preferred.
  • Experience preferably in managed care.
  • Strong preference for experience in fraud investigations, payment integrity, or compliance.
  • Prior experience in a health plan, government program, or investigatory agency SIU preferred.
  • Experience with SAS, Tableau, or other data visualization tools preferred.
  • Knowledge of managed care industry operations, practices, and standards and compliance program practices and elements preferred.
  • Familiarity with claim data structure.
  • Advanced Excel and Power Query skills.
  • Experience with Healthcare Fraud Shield (HCFS) or similar case management platforms is highly desirable.
  • Competitive salary
  • Hybrid schedule
  • State of the art fitness center on-site
  • Medical Insurance with Dental and Vision
  • Life, short-term, and long-term disability options
  • Career advancement opportunities and professional development
  • Wellness programs that promote a healthy work-life balance
  • Flexible Spending Account – Health Care/Childcare
  • CalPERS retirement
  • 457(b) option with a contribution match
  • Paid life insurance for employees
  • Pet care insurance
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