Special Investigation Unit Clinical Healthcare Fraud Investigator III

L.A. Care Health Plan•Los Angeles, CA

About The Position

The Special Investigation Unit Clinical Healthcare Fraud Investigator III leads complex investigations into suspected healthcare fraud, waste, and abuse across all of L.A. Care’s lines of business. This position independently manages full-cycle investigations from intake through closure, develops investigative strategies, prepares evidentiary packages for regulatory or law enforcement referral, and provides clinical and operational insight into healthcare billing patterns and provider behaviors. This position collaborates cross-functionally to safeguard organizational integrity and ensure compliance with federal and state program-integrity mandates by using advance clinical judgment and regulatory knowledge. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.

Requirements

Bachelor's Degree in Nursing or Related Field In lieu of degree, equivalent education and/or experience may be considered.
At least 4 years of experience as a practicing clinician (e.g., nursing, pharmacy, or medical practice).
At least 3 years conducting healthcare fraud investigations, including experience managing complex cases through full lifecycle.
Expertise in clinical documentation review, managed care operations, and regulatory compliance.
Strong understanding of coding and reimbursement structures (including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding Systems (HCPCS), International Classification of Diseases (ICD-10)), medical billing, and claims review processes.
Working knowledge of program-integrity requirements under 42 CFR § 438.608, CMS Chapter 21, and applicable state regulations. Working knowledge of regulatory requirements under 42 CFR § 438.608 and CMS Chapter 21.
Proficiency with Microsoft Office suite and investigative documentation systems. Demonstrated proficiency with data analytics and visualization tools (e.g., Tableau, Excel Power Query, or Power BI).
Strong collaboration skills. Excellent communication and report-writing skills suitable for internal and external stakeholders. Excellent written, verbal, and presentation skills suitable for executive and regulatory audiences.
Ability to read, interpret and draw accurate conclusions from legal and factual information and synthesize findings in clear, professional reports.
Strong working knowledge of federal and state program-integrity regulations. Demonstrated expertise in clinical documentation review, regulatory compliance, and managed-care operations.
Proven ability to mentor others and manage multiple investigations concurrently.
Capacity to prioritize competing demands, meet strict regulatory deadlines, and manage multiple investigations simultaneously.
Active, current, and unrestricted California Clinical License commensurate with clinical degree.

Nice To Haves

Master's Degree in Public Health or Related Field
Prior experience in a Special Investigations Unit (SIU) or payment-integrity environment.
Familiarity with healthcare operational systems and processes.
Current knowledge of emerging fraud, waste, and abuse (FWA) schemes and industry countermeasures.
Working knowledge and understanding of relevant state and federal statutes and the ability to interpret their operational impact.
And/Or any of the following Licenses/ Certifications: Certified Fraud Examiner (CFE) Accredited Health Care Fraud Investigator (AHFI) Certified HealthCare Compliance (CHC) Lean Six Sigma Green Belt Lean Six Sigma Black Belt

Responsibilities

Conducts complex clinical investigations involving provider, member, or vendor misconduct, including the review of claims, clinical documentation, and billing practices.
Conducts interviews, collects and preserves evidence, and maintains proper chain of custody.
Coordinates with law enforcement, regulatory agencies, and internal partners on referrals and case collaboration. Collaborates closely with Compliance, Payment Integrity, and Legal Affairs to ensure effective oversight and timely resolution of potential fraud, waste, and abuse matters.
Analyzes patterns and emerging schemes such as pill-mill activity, upcoding, unbundling, ghost and double billing, and credentialing fraud.
Prepares comprehensive investigative reports and referral packets that meet the evidentiary and procedural standards of the Centers for Medicare & Medicaid Services (CMS) and the California Department of Health Care Services (DHCS).
Supports recovery efforts by identifying overpayments and recommending cost-avoidance strategies.
Mentors’ junior investigators, sharing best practices in case methodology and documentation standards.
Contributes to the enhancement of detection controls and analytic queries to strengthen proactive oversight.
Participates in interdisciplinary task forces focused on emerging risks such as telehealth abuse, pharmacy diversion, and durable medical equipment (DME) fraud.
Apply subject matter expertise in evaluating business operations and processes. Identify areas where technical solutions would improve business performance. Consult across business operations, provide mentorship, and contribute specialized knowledge. Ensure that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provide training and recommend process improvements as needed.
Performs other duties as assigned.