About L.A Care Health Plan: 
Established in 1997, L.A. Care Health Plan is an independent public agency originally 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, including two plans providing affordable coverage for the community at large, we make sure our members get the right care at the right place at the right time. 
 
Our Vision: 
A healthy community in which all have access to the health care they need. 
 
Our Mission: 
L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income residents and to support the safety net required to achieve that purpose. · Reflects a commitment to cultural diversity and the knowledge necessary to serve our members with respect and competence 
 
Our Values: 

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	<li>Accountable and responsive to the communities we serve and focus on making a difference 
	<li>Reflects a commitment to cultural diversity and the knowledge necessary to serve our members with respect and competence • Driven by continuous improvement and innovation and aims for excellence and integrity 
	<li>Demonstrates L.A. Care’s leadership by active engagement in community, statewide and national collaborations and initiatives aimed at improving the lives of vulnerable low income individuals and families
	<li>Fosters and honors strong relationships with our health care providers and the safety net 
	<li>Empowers our members, by providing health care choices and education and encouraging their input as partners in improving their health 
	<li>Puts people first, recognizing the centrality of our members and the staff who serve them
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Job Summary 
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 L.A. Care, 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

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	<li>Conducts complex independent investigations resulting from the discovery of suspicious claims or incidents involving L.A. Care, members and service providers that could potentially involve fraud, waste, or abuse. 
	<li>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. 
	<li>Participates in onsite audits as assigned in conjunction with investigation development.  
	<li>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).  
	<li>Participates at hearings/appeals and can testify as a witness in court proceedings. 
	<li>Initiates the process with L.A. Care’s Recovery Services for recoupment of overpaid monies.
	<li>Submits referrals of suspected fraud cases within mandated period of time as required by DHCS and CMS. 
	<li>Prepares and submits investigative report documenting all phases of an investigation. 
	<li>Compiles and maintains various documentation and other reporting requirements. 
	<li>Maintains chain of custody on all documents and follows all confidentiality and security guidelines. 
	<li>Maintains cases referred to law enforcement and responds to requests for information; pursues applicable administrative actions during investigation/case development.
	<li>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).
	<li>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.
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Direct Hire - Compliance/Contracting/Legal

$80,000 - $100,445/yr

About this job