Temporary Special Investigations Unit Specialist

Impresiv Health•Rancho Cucamonga, CA

2d•Hybrid

About The Position

Impresiv Health is seeking a Special Investigations Unit (SIU) Specialist to support the intake, assessment, coordination, and management of Fraud, Waste, and Abuse (FWA) referrals for a healthcare organization. The SIU Specialist plays a critical role in the early stages of FWA case management, including documenting referrals, conducting preliminary analysis, assessing risk, and prioritizing cases based on potential impact. This position will organize, analyze, and report referral data while utilizing case management and FWA analytics tools to support proactive fraud detection and investigation efforts. This role requires strong analytical skills, attention to detail, advanced Microsoft Excel capabilities, and an understanding of healthcare operations, compliance, and regulatory requirements. The position also supports organizational quality initiatives, including applicable HEDIS, CAHPS, and NCQA Accreditation goals.

Requirements

Minimum of three (3) years of experience within a healthcare environment.
High School Diploma or GED required.
Demonstrated proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
Intermediate to advanced Microsoft Excel proficiency required, including experience with tools such as pivot tables, Power Query, conditional formatting, formulas, and macros.
Strong interpersonal, written, and verbal communication skills.
Strong organizational, analytical, and problem-solving abilities.
Demonstrated ability to work both independently and collaboratively within a team environment.
Ability to effectively manage multiple priorities and deadlines.
Strong commitment to confidentiality, integrity, compliance, and ethical decision-making.

Nice To Haves

Managed care experience is strongly preferred.
Experience in healthcare fraud investigations, Fraud, Waste, and Abuse, compliance, or a related function is strongly preferred.
Associate degree or bachelor’s degree from an accredited institution preferred.
Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or a similar healthcare fraud, coding, billing, or compliance certification preferred.
Knowledge of managed care industry operations, practices, standards, and compliance program requirements preferred.
Experience with Healthcare Fraud Shield (HCFS) or comparable healthcare fraud analytics or case management platforms is highly desirable.

Responsibilities

Oversee the intake process for Fraud, Waste, and Abuse referrals, conduct preliminary assessments, and determine the urgency, risk, and potential impact of each referral.
Triage, manage, prioritize, and track referrals using case management and FWA analytics applications while maintaining the accuracy and integrity of case data.
Utilize intermediate to advanced Microsoft Excel functionality, including pivot tables, Power Query, conditional formatting, formulas, and macros, to organize and analyze referral data.
Develop reports and analyze data to identify patterns, trends, and potential areas of risk.
Conduct preliminary investigations by gathering relevant information, reviewing available data, performing initial analyses, and preparing findings for SIU Investigators.
Identify and escalate high-risk, complex, or sensitive issues to appropriate SIU personnel or management.
Collaborate with Compliance Analysts, Investigators, and other stakeholders to support effective case triage, evaluation, and handoff.
Maintain accurate, complete, and comprehensive documentation of FWA referrals within the case management system for audit, regulatory, and legal purposes.
Identify opportunities to improve SIU intake processes, workflows, and operational efficiency.
Create, maintain, and update standard work, workflows, procedures, and documentation relevant to SIU operations.
Maintain knowledge of applicable federal and state healthcare regulatory requirements and ensure issues are addressed in a timely manner.
Support departmental and health plan operational needs as required.