Special Investigation Unit Investigator II

L.A. Care Health Plan seeks a Special Investigation Unit Investigator II to conduct complex independent investigations of alleged fraudulent billing and other suspected fraudulent activities related to L.A. Care, members and providers.

Requirements

• Conducts complex independent investigations resulting from the discovery of suspicious claims or incidents
• Reviews information contained in standard claims processing system files
• Participates in onsite audits as assigned
• Completes investigation after referrals to law enforcement
• Participates at hearings/appeals and can testify as a witness in court proceedings
• Submits referrals of suspected fraud cases within mandated period of time
• Prepares and submits investigative report documenting all phases of an investigation
• 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
• Proactively seeks out and develops leads received from fraud tips and any variety of sources
• Participates in industry meetings/trainings and is able to effectively share and gather significant information
• Liaises with industry peers and where necessary, interfaces appropriately with law enforcement
• Continually enhances investigative skills and understanding of emerging issues and trends impacting the industry

Benefits

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