Job Title: Healthcare - Care Review Clinician I (Temp-to-Perm)

Pay Rate: $40-$42/hr
Schedule: Monday – Friday, 8:00 AM – 5:00 PM PST
Location: Remote, but candidate must reside in Southern California and hold a valid CA RN license
* Travel Reimbursed at IRS rates

Job Description
A Managed Care Organization is seeking an experienced Registered Nurse (RN) with a strong background in fraud, waste, and abuse investigations to work within the Corporate Special Investigations Unit (SIU). This RN will perform work on behalf of the CA Health Plan, reviewing CLIA certification documentation from non-participating laboratories, contacting both labs and members, and assisting with fraud, waste, and abuse inquiries. The RN may also conduct on-site investigations to validate the presence of proper laboratory equipment and ensure compliance with regulatory standards. This is a temp-to-hire opportunity, with the potential for long-term placement based on performance and business needs.

Key Responsibilities

• Review CLIA certification documentation from non-participating laboratories.

• Contact non-participating labs and CA Health Plan members regarding documentation compliance.

• Report findings to SIU leadership, including suspected fraud, waste, and abuse cases.

• Conduct on-site inspections at non-participating laboratories to verify compliance with regulatory standards.

• Assist with other referrals to SIU related to fraud, waste, and abuse within the CA Health Plan.

• Collaborate with managed care stakeholders to ensure regulatory compliance and proper documentation.

Required Skills & Qualifications

• Active CA Registered Nurse (RN) license.

• Reside in Southern California (preferred).

• Strong background in fraud, waste, and abuse investigations within healthcare.

• Hospice experience preferred.

• Case management experience preferred.

• Ability to analyze documentation for compliance and detect potential fraud.

• Strong communication skills to interact with laboratories, members, and healthcare providers.

• Ability to travel within California as needed for on-site investigations (expected a few times per year).

Preferred Experience

• Prior experience in managed care, SIU, or compliance investigations.

• Experience working with healthcare fraud detection units.

Additional Information

• This is a temp-to-perm position based on performance and business needs.

• Candidates must be detail-oriented, investigative, and highly accountable in fraud investigations.