Healthcare Compliance Specialist 26-00251

Special Investigations Unit Specialist

Position Type: Temporary Schedule: M-F, 8:00 am - 5:00 pm Assignment Length: Approximately 6-Months, possibly longer.

The Special Investigations Unit (SIU) Specialist is responsible for the intake, initial assessment and coordination of Fraud, Waste, and Abuse (FWA) referrals within the SIU. This role plays a critical part in the early stages of case management, including the documentation, initial analysis, and prioritization of FWA issues according to risk and potential impact. The Specialist organizes, analyzes, and reports referral data, and utilizes the Plan's case management application and FWA analytics tools to support the SIU in proactive FWA detection.

Key Responsibilities

• Oversee the intake process for all FWA referrals, conduct preliminary assessments, and determine the urgency and potential impact of each referral to prioritize further actions.
• Triage, manage, and track referrals using the case management and FWA analytics application, ensuring case data integrity throughout the intake process. Utilize advanced Microsoft Excel tools (e.g., pivot tables, Power Query, conditional formatting, formulas, macros) to organize and analyze referral data, generate reports, and support trend identification.
• Conduct preliminary investigations by gathering necessary data, conducting initial analyses, and preparing reports for SIU Investigators. Escalate high-risk or complex issues to appropriate SIU staff or management.
• Collaborate with Compliance Analysts and Investigators to support case triaging and handoff through the FWA analytics and detection application.
• Maintain accurate and comprehensive records of all FWA referrals in SIU's case management system for audit and legal purposes.
• Identify and recommend improvements in intake processes to enhance the efficiency and effectiveness of the SIU.
• Create and maintain standard work specific to workflows and procedures relevant to the role.
• Keep abreast with Federal and State regulatory requirements and respond timely to resolve issues.
• Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Requirements

• Minimum of three (3) years of experience in a healthcare environment
• Experience preferably in managed care
• Strong preference for experience in fraud investigations or compliance
• High School diploma or GED required
• Associate degree or bachelor's degree from an accredited institution preferred
• Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar certification related to healthcare fraud, coding, and billing is preferred

Key Qualifications

• Knowledge of managed care industry operations, practices, and standards and compliance program practices and elements preferred
• Demonstrated proficiency in Microsoft Office products (Word, Excel, PowerPoint, Outlook, etc.) as tested by IEHP
• Intermediate to advanced proficiency in Microsoft Excel is required
• Experience with Healthcare Fraud Shield (HCFS) or similar case management platforms is highly desirable
• Excellent interpersonal skills. Effective communication skills; verbal and written.
• Strong analytical skills
• Proven ability to work independently and as part of a team in a high-stakes environment
• Ability to manage multiple cases and projects with competing deadlines
• Excellent interpersonal and communication skills, capable of working effectively across various departments and with external partners
• Detail-oriented
• Strong commitment to integrity and ethical decision-making