Senior SIU Investigator

Job Category:  Administrative, HR, Business Professionals
Department:  Payment Integrity
Location: 

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  3887

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Senior SIU Investigator will perform 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 & abuse. In addition, this role will be responsible for building the investigative approach and provide leadership for Investigators through mentoring, on-site audit leadership, and hands-on training of investigative techniques.

Responsible for in-depth investigations for suspected fraud or abuse with respect to provider, pharmacy, employer, and member across products at L.A. Care Health Plan. Ensures adherence to L.A. Care Health Plan policies and procedures for its various product offerings. Conducts investigation-related training.

Duties

Perform Investigations: Investigates allegations and complex issues pertaining to potential health care fraud by providers or members; 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. Makes potential fraud & abuse determinations by utilizing a variety of sources and initiates appropriate action; Conducts independent investigations as the result of case referrals and/or analytics that potentially involve fraud or abuse; Writes comprehensive investigatory/fact-finding reports and summaries documenting interviews and findings.

Compiles and maintains various documentation and other reporting requirements as needed. Performs other duties as assigned by management including special projects that demonstrate team leadership abilities and support.

Build Relationships: Works cross functionally to build fraud & abuse investigative process; Develops and maintains strong working relationships with associates and regulators including DHCS, DOJ, etc.

Performs other duties as assigned.

Education

Bachelor's Degree

In lieu of Degree, relevant experience may be considered.

Experience

Required:

With Bachelor's Degree: 5 years of experience conducting fact-finding interviews or investigations to

gather information and draw conclusions from various accounts and versions of the same event.

Preferred:

With Master's Degree: 3 years of experience conducting fact-finding interviews or investigations to gather

information and draw conclusions from various accounts and versions of the same event.

Equivalent Experience:

With High School Diploma/GED: 10 years of experience conducting fact-finding interviews or investigations

to gather information and draw conclusions from various accounts and versions of the same event.

With Associate's Degree: 7 years of experience conducting fact-finding interviews or investigations to gather information and draw conclusions from various accounts and versions of the same event.

Skills

Required:

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.

Understanding of the vital importance of commitment to excellence and demonstrating a high regard for organizational values.

Ability to maintain in-depth working knowledge of fraud identification and investigation techniques and provide technical support and guidance to less experienced team members.

Professional Licenses

Preferred:

A license in one of the following: Preferred Other Accredited Healthcare Fraud Investigations (AHFI) or Certified Fraud Examiner (CFE)

Additional Information

 

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)


Nearest Major Market: Los Angeles

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