Manager, Special Investigations Unit Medical Record Audit

Overview What you can expect!  Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an  authentic experience! Under the direction of the Vice President of Compliance, and in close partnership with the Special Investigations Unit (SIU) Manager, the SIU Medical Record Audit Manager provides leadership and strategic direction for IEHP’s prepayment and post-payment medical record audit functions within the Fraud, Waste, and Abuse (FWA) framework. This role holds primary authority over medical record audit operations and is accountable for the accuracy, consistency and defensibility of every audit determination issued by the unit. The SIU Medical Record Audit Manager oversees and develops a team of Medical Record Auditors, directing complex coding and documentation audits of medical records and claims to determine the accuracy, appropriateness, and compliance of billed services under federal and state requirements applicable to each line of business. The incumbent holds final determination authority on coding, billing, and documentation-sufficiency findings, and is responsible for generating measurable financial impact through overpayment identification, cost‑avoidance recommendations, prepayment intervention, and remediation of the payment vulnerabilities that audits surface. In addition to daily leadership of staff, the SIU Medical Record Audit Manager designs, implements, and continuously improves review methodologies, performance metrics, quality assurance protocols, and reporting frameworks that strengthen IEHP’s program integrity posture and withstand regulatory, provider, and judicial challenge. The incumbent ensures medical record audit operations are executed with precision, consistency, and alignment to IEHP’s strategic compliance objectives, while proactively identifying risks, monitoring trends, and evaluating the effectiveness and outcomes of all medical record audit activities on an ongoing basis.  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 Benefits Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account – Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities Operational Leadership & Oversight Provide strategic and operational leadership for SIU’s prepayment and post payment medical record audit program. Establish and maintain audit strategies, standards, SOPs, KPIs, and QA methodologies aligned with Compliance and program integrity objectives. Develop operational dashboards to monitor turnaround, work in process aging, determination quality, corrective action timeliness, and appeal uphold rates. Oversee audit documentation quality for regulatory submissions and support formal responses to DHCS, DMHC, CMS, and law enforcement entities. Ensure team adherence to ethical conduct, confidentiality requirements, and audit ready file maintenance. Prepayment Review Performance Lead end to end prepayment medical record review operations, including documented criteria for placing and releasing providers, turnaround compliance within claims payment timeframes, yield optimization, false positive monitoring, inventory aging, and scheduled reassessment and exit decisions. Identify payment vulnerabilities surfaced through prepayment reviews and route systemic findings for corrective remediation. Ensure prepayment activities produce measurable cost avoidance impact. Post Payment Audit Quality Direct and review post payment medical record audits, claim reviews, and documentation sufficiency determinations. Serve as the final determination authority on coding, billing, and regulatory compliance findings, ensuring every determination is supported by controlling authority for the applicable line of business. Maintain audit accuracy and defensibility in preparation for provider appeals, regulatory review, and potential judicial challenge. Ensure audit outcomes support timely overpayment identification, fraud referral reporting, and financial recovery expectations. Quality Assurance, Continuous Improvement & Sampling Integrity Implement and oversee a comprehensive QA program including internal reviews, vendor oversight, random sampling, error typology tracking, and corrective action development. Lead SOP refinement, criteria clarification, retraining, and process improvement initiatives in response to identified variances. Provide technical guidance to support probe reviews, statistically valid samples, extrapolated findings, and review integrity. Partner with SIU Investigators on sample design, stratification methodology, and interpretation of sample results. Appeals, Disputes & Regulatory Defense Lead audit determination defense across provider disputes, appeals, regulatory audits, and legal proceedings. Conduct or direct reconsideration reviews, ensuring determinations meet defensibility standards and uphold the correct application of regulatory and coding authority. Deliver audit findings to IEHP leadership, Compliance, regulators, law enforcement, and legal entities as needed. Maintain a strong sustain rate across all challenged determinations. Regulatory Reporting, Policy Ownership & Team Leadership Ensure timely delivery of required regulatory reports, fraud referrals,