Special Investigation Unit Investigative Analyst III

L.A. Care Health Plan•Los Angeles, CA

5d•$67,186 - $107,498

About The Position

The Special Investigation Unit (SIU) Investigative Analyst III is responsible for overseeing the initial intake and regulatory reporting of all source investigative leads. The SIU Analyst III triages all investigative leads including hotline complaints, e-mail reports, referrals from the Credentialing Department, referrals from Law Enforcement and referrals from Federal and State regulatory agencies. This includes review of the investigative lead and entering the complaint information into the Health Care Fraud Shield (HCFS) case management data system and the preparation of the Federal and State regulatory reports. This position ensures that these regulatory reports are submitted onetime, within the 10-day reporting period. The SIU Analyst III serves as the point of contact with the Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS). This position takes the lead in developing the reporting functions of HCFS and maintains regular contact with HCFS on issues relating to the development and reconstruction of the HCFS reporting system. This position also is responsible for analyzing all new case leads to determine if Planned Partners (PPs) or Professional Provider Groups (PPGs) require notification. If the PP/PPGs have an investigative jurisdiction, the SIU Analyst III ensures the proper CMS and DHCS reports are sent to the agencies in a timely manner. The SIU Investigative Analyst III oversees data analysis in support of ongoing Investigative matters and assists SIU Investigators in the development of reporting for complex health care fraud investigations. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Requirements

Associate's Degree (In lieu of degree, equivalent education and/or experience may be considered).
Minimum of 4 years of experience in healthcare fraud investigation/ detection.
Strong project leadership skills; ability to prioritize, plan and handle multiple tasks/demands simultaneously.
Ability to support heavy workload volume and meet critical regulatory guidelines.
Understanding of Federal and State healthcare fraud regulatory reporting requirements.
Strong understanding of HCFS and HPMS.
Understanding of healthcare operational systems and processes.
Strong understanding of Accurint, MS Excel, Word, PowerPoint, SharePoint.
Ability to navigate and master L.A. Care proprietary software programs.
Excellent verbal and written communication skills.
Strong knowledge of standard industry coding guides such as CPT, HCPCS, ICD-10 CMS 1500 and UB04 data elements.
Knowledge of the Healthcare Fraud Shield Case Management system.
Knowledge of state and federal laws and ability to interpret and take action on the aspects of such laws that impact the business.

Nice To Haves

Bachelor's Degree
Experience in CA Medi-Cal/ Medicare/ Medicaid Services Payment Services.
Certified Medical Coder
Accredited Health Care Fraud Investigator (AHFI)

Responsibilities

Oversees the initial intake, triage and regulatory reporting of all investigative leads including hotline complaints, e-mail reports, referrals from the Credentialing Department, referrals from Law Enforcement and referrals from Federal and State regulatory agencies.
Ensures Federal and State regulatory reports (CMS and DHCS) are submitted onetime, within the 10-day reporting period.
Serves as a Subject Matter Expert (SME) on the HCFS Data system and is the point of contact to HCFS on matters of system updates regarding the development and updates of the HCFS reporting system.
Evaluates investigative leads and determines if the need exists to distribute these leads to PP or PPGs.
Uses knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources.
Prepares clear and concise investigative reports to support analytical findings, recommendations, and actions.
As a Subject Matter Expert, develops and conducts training on unit processes, for lower-tiered positions.
Performs other duties as assigned.