Job Title:

Temporary Special Investigations Unit (SIU)

Specialist Job Type:

Full-Time Temporary Contract (Up to 6 Months)

Location:

Rancho Cucamonga, CA 91730

Work Schedule:

Hybrid (Mon & Fri Remote / Tue-Thu Onsite) Position Overview The Special Investigations Unit (SIU) Specialist plays a vital role in the intake, preliminary assessment, tracking, and coordination of Fraud, Waste, and Abuse (FWA) referrals for a leading health plan. This position supports the Special Investigations Unit by evaluating incoming referrals, performing data analysis, maintaining detailed case records, and assisting investigators with preliminary case development to ensure regulatory integrity across all healthcare operations.

Key Responsibilities Referral Intake & Assessment:

Manage the intake process for FWA referrals; conduct preliminary reviews to evaluate referral urgency, risk levels, and potential clinical or financial impacts.

Case Triage & Tracking:

Log, track, and maintain accurate case details within SIU case management systems and specialized FWA analytics platforms.

Data Analysis & Excel Modeling:

Gather, synthesize, and analyze complex healthcare data sets to support preliminary investigations using advanced Microsoft Excel functionality (Pivot Tables, Power Query, formulas, and conditional formatting).

Reporting & Escalation:

Prepare preliminary investigation summaries and reports for SIU Investigators and leadership; escalate high-risk or complex issues to designated investigative staff promptly.

Compliance & Recordkeeping:

Maintain complete, audit-ready records in full alignment with state, federal, and internal regulatory compliance standards.

Cross-Functional Collaboration:

Partner with Compliance Analysts, Investigators, and internal stakeholders throughout the case management lifecycle.

Process Improvement:

Identify emerging fraud trends, suggest workflow enhancements, and maintain standard operating procedures (SOPs) for the SIU department.

Minimum Qualifications Experience:

Minimum of three (3) years of operational experience within a healthcare environment.

Education:

High School Diploma or GED required.

Technical Skills:

Intermediate to advanced proficiency in Microsoft Excel (Pivot Tables, Power Query, complex formulas, data analysis tools).

Core Competencies:

Proven analytical ability, strong written and verbal communication, keen attention to detail, and sound judgment in maintaining confidentiality. Preferred Qualifications Associate's or Bachelor's degree in Healthcare Administration, Business, Criminal Justice, or a related field. Previous experience in managed care, healthcare compliance, fraud/waste/abuse (FWA) investigations, or healthcare auditing. Experience with specialized fraud detection tools or case management software (e.g., Healthcare Fraud Shield / HCFS). Experience creating or running Excel Macros. Professional certifications such as Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or Certified Fraud Examiner (CFE). Medical, dental, and vision insurance are available to qualified candidates who meet eligibility requirements.