Lead Special Investigation Unit Investigator

L.A. Care Health Plan•Los Angeles, CA

14h•$88,854 - $142,166

About The Position

The Lead Special Investigations Unit Investigator works as an integral member of the Special Investigations Unit (SIU) performing as a Lead team member, providing oversight and guidance with provider training communications and documentation, fraud data analysis, data mining, non-fraud referrals, and the training of SIU team members. This position will also carry an investigative case load, conduct interviews, prepare investigation reports and make referrals to law enforcement.

Requirements

Bachelor's Degree in Criminal Justice or Accounting
At least 5 years of experience in healthcare fraud investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, interviewing, report writing and making appropriate decisions.
Minimum of 2-3 years of lead experience.
Excellent research skills and the ability to support conclusions with documentary evidence.
Excellent analytical, problem solving, and resolution skills and the ability to discern the practical application of regulatory and legal requirements.
Demonstrated ability to manage multiple demands and priorities.
Strong organizational skills to perform multiple work assignments.
Excellent and effective communication skills, both verbal and written, across the organization at varying levels.
Proficient computer skills, including computer applications such as MS Word and Excel.
Light Physical Requirements

Nice To Haves

Master's Degree in Criminal Justice or Accounting
Accredited Health Care Fraud Investigator (AHFI)
Certified Fraud Examiner (CFE)

Responsibilities

Conducts independent investigations resulting from the discovery of suspicious claims or incidents involving L.A. Care, members and service providers that could potentially involve fraud, waste, or abuse.
Utilizes data analysis techniques to detect unusual billing claims data, and proactively seeks out and develops leads received from fraud tips and any variety of sources (e.g., fraud alerts, media).
Reviews information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medi-Cal/Medicare policies and initiates appropriate action.
Completes investigation after referrals to law enforcement (Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) and Department of Justice (DOJ) or local police) and initiate process with L.A. Care’s Recovery Services to recoupment overpaid monies.
Participates if requested in onsite audits in conjunction with investigation development.
Participates at hearings/appeals and testify as a witness in court.
Submits referrals of suspected fraud cases within mandated period of time as required by DHCS and CMS.
Prepares and submits investigative report documenting all phases of an investigation.
Compiles and maintains various documentation and other reporting requirements.
Maintains chain of custody on all documents and follows all confidentiality and security guidelines.
Maintains cases referred to law enforcement and responds to requests for information; pursues applicable administrative actions during investigation/case development.
Leads the Compliance CMS Fraud Waste and Abuse training program for providers.
Directs oversight of the referral intake process, logging, tracking and development of leads presented to the SIU.
Leads and assists Investigative Analyst in preparation of detailed analysis of SIU data for internal and external audit reports.
Participates in industry meetings/training and is able to effectively share and gather significant information.
Liaisons with industry peers and where necessary, interfaces appropriately with law enforcement.
Continually enhances investigative skills and understanding or emerging issues and trends impacting the industry.
Performs other duties as assigned by Management that contribute to SIU goals and objectives.
Performs other duties as assigned.