Special Investigation Unit Investigator III

Job Summary

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.

Responsible for in-depth investigations requiring subject matter expertise for suspected provider, pharmacy, employer or member fraud or abuse across all products at L.A. Care Health Plan. Ensures adherence to L.A. Care's policies and procedures for its various product offerings. Conducts investigation-related training. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

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.

Participates in industry meetings/trainings and is able to effectively share and gather significant information.  Develops and maintains strong working relationships with associates and regulators including DHCS, DOJ the FBI, Local Law Enforcement, Prosecutors, etc. Continually enhances investigative skills and understanding of emerging issues and trends impacting the industry.

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.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

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: 

Diverse experience as subject matter expert (SME) with multiple specialties including: Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental etc.

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 strong organizational skills and the ability to manage multiple demands and priorities.

Excellent and effective communication skills, both verbal and written.

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 investigation techniques and mentor less experienced team members.

Preferred:

Proficiency with Access.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information