Special Investigation Unit Investigator III

The Special Investigation Unit Investigator III performs in-depth evaluation of potential fraud & abuse cases and develops complex investigations that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for fraud, waste & abuse. In addition, this position is responsible for building the investigative approach and provide leadership for Investigators through mentoring, on-site audit leadership and hands-on training of investigative techniques.

Investigates allegations and complex issues pertaining to potential health care fraud by providers or members. Makes potential fraud & abuse determinations by utilizing a variety of sources including data analytics to detect unusual billing. Proactively seeks out and develops leads received from fraud tips and any variety of sources (e.g., fraud alerts, media) and initiates appropriate action. Writes comprehensive investigatory/fact-finding reports and summaries documenting interviews and findings. Reviews information contained in standard claims processing system files (e.g. claims history, provider files) to determine provider billing patterns and detect potential fraudulent or abusive billing practices or vulnerabilities in Medi-Cal/Medicare policies and initiates appropriate action. This position is a leader at onsite audits as assigned in conjunction with investigation development. Completes investigations after referrals to law enforcement (Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), Department of Justice (DOJ) or local police). Participates at hearings/appeals and can testify as a witness in court proceedings. Initiates the process with L.A. Care’s Recovery Services for recoupment of overpaid monies.

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 while following 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.

Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Minimum of 5 years of experience in healthcare fraud investigation/detection and/or healthcare related specialty including but not limited to; Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental etc.

Experience conducting fact-finding interviews or investigations to gather information and draw conclusions from various accounts and versions of the same event.

Experience managing large amounts of data including pivot tables, complex calculations, and ability to perform comparisons across multiple large data sets

Preferred: