IEHP

Threat Intelligence Specialist

• 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.
• Conduct data mining, statistical trend analysis, and anomaly detection to validate leads.
• Escalate high-impact patterns for formal investigation.
• Collaborate with investigations and cross-functional teams to support SIU operations.
• Incorporate IEHP’s Quality Program goals including HEDIS, CAHPS, and NCQA Accreditation into work.
• Manage multiple projects and competing deadlines in a high-stakes environment.
• Work independently and as part of a team to detect FWA and support compliance efforts.
• Interpret complex claims data and identify red flags.

SIU Intelligence Analyst

Manager

• Provide high quality, effective care management to IEHP members ensuring coordinated continuous care
• Conduct outreach and engagement, skilled therapeutic interactions, behavioral health interventions within scope, care coordination, and resource linkages
• Utilize clinical expertise to support and engage Members to promote positive health behaviors and assist with coordination of care
• Provide clinical expertise, clinical leadership, and clinical oversight; consult for non-licensed team members
• Conduct comprehensive holistic assessments telephonically and in person (facility or home visits) and develop individualized care plans or discharge plans
• Coordinate with internal and external health partners, participate in inter/transdisciplinary care team meetings, and facilitate transitions of care
• Provide crisis intervention and clinical guidance; engage in proactive utilization and quality review of Behavioral Health services
• Lead and provide clinical training and onboarding for department Team Members on behavioral health conditions and evidence-based treatments
• Ensure documentation accuracy and compliance with regulatory requirements and accreditation standards
• Assist Members with care coordination needs including PCP appointments, transportation, DME, and home health coordination

Licensed Behavioral Health Care Manager – Crisis Queue

• 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

Intelligence Analyst

Supply Chain

The Procurement Contract Specialist II - Supply Chain Management (PCS II - SCM) will purchase and negotiate on behalf of IEHP in the development of the most difficult, high dollar, and complex, multi-year, and/or multi-departmental procurement, contracts and awards for professional services, consultant services, materials, supplies, and equipment.
• The PCS II - SCM leads departments in selection of the most equitable and efficient solicitation process, in negotiations, and for major contract implementation and management.
• The PCSII - SCM is the advanced level in the Procurement Contract Specialist class of the Procurement Department.
• Incumbents provide technical supervision and training to Procurement Contract Specialists.
• The Procurement Contract Specialist II - Supply Chain Management reports to the Procurement Supervisors and supports the Procurement Manager.
• This position possesses knowledge of the most appropriate procurement/contract type to reduce IEHP's exposure to risk, in alignment with public procurement policies, regulations, industry standards, ensuring compliance with IEHP’s Procurement, Legal, and Governing Board policies, and State and Federal requirements that govern public sector solicitations, award, and administration of contracts.
• Additional responsibilities include applying Lean principles and methodologies in measuring and mitigating contract, cost, and vendor performance risks.
• Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.
• Additional responsibilities include applying Lean principles and methodologies in measuring and mitigating contract, cost, and vendor performance risks.
• Any other duties as required ensuring Health Plan operations are successful.

Procurement Contract Specialist II – Supply Chain

• Establish and continuously model supportive and collaborative relationships with members, colleagues, and external partners.
• Model the highest ethical behavior in care for Members, as well as in relationships with co-workers, Leaders, internal, and external partners.
• Model commitment to continuous quality improvement by engaging in quality improvement initiatives and projects, such as by identifying and addressing HEDIS gaps, and by identifying, developing, and testing new practices for improving the outcomes of the Enhanced Care Management team.
• Participates in Health Plan staff meetings, trainings, committee meetings, or other activities as needed or as directed by Leadership Team Members.
• Working in a lead training capacity by providing formal and informal clinical training and other learning and development activities to support department Team Members on behavioral health conditions, including treatments and evidence-base for treatment (within areas of expertise/scope) as well as provide onboarding and ongoing training to department Team Members.
• Promote a collaborative and effective working environment within the department or those outside BH discipline by engaging in evidenced-based communication strategies (such as Motivational Interviewing) when discussing responsibility/sharing of tasks, effectively resolving conflicts as they arise, and collaborating on Member case discussions to provide integrated care to IEHP members.
• Participate in committees, conferences, and any other meetings as required or directed by department managers or directors.
• Responsible for primarily working with a caseload of Members with behavioral health needs.
• Advocate for Members to receive the highest quality care, in a timely manner, within IEHP’s network by referring to appropriate internal partners such as behavioral health, Enhanced Care Management, and complex care management.
• In conjunction with department leadership, the Licensed Behavioral Health Care Manager is responsible for providing consultation for the non-licensed Members of the team when discussing tasks of a clinical nature.
• Responsible for engaging with Members to provide effective care management, both in-person and on the phone, including linkage to resources and support in transitions of care, in a manner that utilizes evidence-based approaches (such as Motivational Interviewing) that promotes collaboration between the Member and his or her medical/behavioral team, facilitating member self-efficacy and self-management to improve the Member’s ability to manage their own health, and all other activities associated with high quality, evidenced-based care management.
• Ensures documentation is accurate and in compliance with regulatory requirements and accreditation standards.
• Assist Members with care coordination needs, including, but not limited to the following: Conduct comprehensive, holistic assessment both telephonically as well as in person (facility or home visits). Assimilate assessment information to assist, in collaboration with the ITC Team and the facility, in developing a discharge plan or an individualized care plan (ICP). Communicate ICP or discharge plan with Member, approved family or caregiver and other Members of the care team. • ...

Temporary Behavioral Health Care Manager, Licensed

Actuary

• Leads on-going analyses of financial, budgetary or medical claims data, through forecasting, statistical analyses, trending, regression analyses, risk assessment, and utilization assessment.
• Identifies key issues and trends and brings them to the attention of higher-level staff members.
• Uses professional concepts and internal policies and procedures to solve problems or provide suggestions.
• Builds financial models to support operational initiatives and analytical endeavors and enable decision-making on business and strategic matters.
• Quantifies the financial impact of opportunities or expenditures.
• Tests and reconciles all financial models and analytic results.
• Provides on-going financial analyses.
• Consolidates a wide-range of operating and financial projections for the development of short- and long-term business plans.
• Works on complex financial analysis projects more independently and under supervision of a more senior staff member if required.
• Monitors, analyzes and evaluates complex data using statistical tools to identify variances, problems and trends.
• May be responsible for bigger projects.
• Generates and distributes regularly scheduled actuarial reports.
• Reviews and organizes actuarial and operational data for reports.
• Utilizes statistical tools to monitor and provide ongoing analysis of these reports, noting any aberrant data.
• May be responsible in the preparation of complex reports.
• Participates or leads in a variety of special studies and ad hoc analyses in support of departmental business and/or clinical objectives.
• Researches and resolves data integrity issues.
• Works independently or with other departments to solve problems.
• Acts as a resource to staff in other departments, providing information and explanations related to financial data as needed.
• Answers most questions and refers highly complex issues to others.
• May participate in workgroups or meetings.
• Communicates and presents financial analyses and models to appropriate audiences.
• May assist in training staff on the use of financial reports and data.
• Performs a variety of ad hoc data and actuarial analysis requests.

Analyst III - Actuarial Services

• Care management is broadly defined, and can include outreach and engagement to Members, engaging Members in skilled therapeutic interactions to promote health behaviors, other behavioral health interventions within scope, coordination of care, resource linkages, working with other professionals and organizations in the community to ensure quality of care for Members, seamless transitions of care, and facilitating the right care and the right time for the member.
• Works collaboratively with Members of their own team, Members and families, and other professionals, in addition to working collaboratively with the designated health care organization (HCO) medical team.
• As a licensed clinician, provides clinical expertise, clinical leadership, and clinical oversight in a variety of ways within the ECM program and Behavioral Health Care management departments.
• Models behavioral health principles of relationship-based care, and promotes education and understanding of behavioral health and its importance in whole health.