Special Investigations Unit (SIU) Investigator – Healthcare Fraud

Job Title:Special Investigation Unit Investigator II Location

Los Angeles, CA Job description The Special Investigation Unit Investigator II is the journeyman level Investigator position for the Special Investigations Unit (SIU).

This position conducts complex independent investigations of alleged fraudulent billing and other suspected fraudulent activities related to client, members and providers.

The position works closely with the department heads on potential fraud, waste and abuse areas.

This position ensures investigations are conducted objectively and are lawfully compliant.

The Investigator II thoroughly gathers all material facts and presents an accurate and objective accounting of the issues.

Duties Conducts complex independent investigations resulting from the discovery of suspicious claims or incidents involving client, members and service providers that could potentially involve fraud, waste, or abuse.

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 or vulnerabilities in Medi-Cal/Medicare policies and initiates appropriate action.

Participates in onsite audits as assigned in conjunction with investigation development.

Completes investigation 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 client’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.

Maintains chain of custody on all documents and follows 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.

Utilizes data analysis techniques to detect unusual billing claims data, and proactively seeks out and develops leads received from fraud tips and any variety of sources (e.g., fraud alerts, media).

Participates in industry meetings/trainings and is able to effectively share and gather significant information.

Able to liaison with industry peers and where necessary, interface appropriately with law enforcement.

Continually enhances investigative skills and understanding of emerging issues and trends impacting the industry.

Perform other duties as assigned.

Duties Continued Education Required Bachelor's Degree in Criminal Justice or Related Field In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred Master's Degree in Criminal Justice or Related Field Experience Required

Minimum of 3 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.

Preferred

Demonstrated investigative and/or health care expertise.

Experienced in reviewing, analyzing/developing information to include interviewing, report writing and decision making.

Skills Required

Excellent research skills and the ability to support conclusions with documentary evidence.

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.

Licenses/Certifications Required Licenses/Certifications Preferred Certified Fraud Examiner (CFE) Accredited Health Care Fraud Investigator (AHFI) Certified Professional Coder (CPC) designation by the American Academy of Professional Coders Must-haves Minimum of 3 years of experience in healthcare fraud investigation/detection Healthcare-related specialty, including but not limited to

Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental, etc.

Ideally, in Managed Care Experience with managing high-volume case load with experience drafting executive summaries Less Common Requirements Master Degree Required Skills Minimum of 3 years of experience in healthcare fraud investigation/detection Healthcare-related specialty, including but not limited to

Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental, etc.

Ideally, in Managed Care Experience with managing high-volume case load with experience drafting executive summaries Preferred or Nice-to-have Skills Preferred working in a Managed Care setting Master’s Degree