Temporary Special Investigations Unit Specialist

Job Description

Job Description

Location : Hybrid | Remote on Mondays and Fridays; onsite Tuesday through Thursday in Rancho Cucamonga, CA

Description:
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.

What You Will Do:

• 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.

You Will Be Successful If:

• You possess strong analytical and critical-thinking skills and can effectively evaluate complex information.
• You are highly detail-oriented and committed to maintaining accurate documentation and data integrity.
• You can independently manage multiple referrals, cases, projects, and competing deadlines.
• You are comfortable working in a high-stakes environment involving sensitive healthcare, compliance, and investigative matters.
• You demonstrate sound judgment, integrity, confidentiality, and ethical decision-making.
• You communicate clearly and professionally, both verbally and in writing.
• You collaborate effectively with investigators, compliance professionals, internal departments, and external partners.
• You are proficient in analyzing large or complex datasets and translating findings into actionable information.
• You understand managed care operations, healthcare compliance, fraud prevention, or related healthcare business functions.
• You are proactive in identifying process improvements and opportunities to increase operational effectiveness.

What You Will Bring:

• Minimum of three (3) years of experience within a healthcare environment.
• Managed care experience is strongly preferred.
• Experience in healthcare fraud investigations, Fraud, Waste, and Abuse, compliance, or a related function is strongly preferred.
• 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 a similar healthcare fraud, coding, billing, or compliance certification preferred.
• Knowledge of managed care industry operations, practices, standards, and compliance program requirements preferred.
• 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.
• Experience with Healthcare Fraud Shield (HCFS) or comparable healthcare fraud analytics or case management platforms is highly desirable.
• 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.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do: provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That s Impresiv!