Special Investigation Unit Investigator II

Salary Range $77,265.00 (Min.) - $100,445.00 (Mid.) - $123,625.00 (Max.) 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, 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 Special Investigation Unit Investigator II is a 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 role works closely with department heads on potential fraud, waste, and abuse areas, ensuring 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. Responsibilities Conduct complex independent investigations resulting from the discovery of suspicious claims or incidents that could involve fraud, waste, or abuse. Review information in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns, detecting potential fraudulent or abusive billing practices or vulnerabilities in Medi‑Cal/Medicare policies, and initiate appropriate action. Participate in onsite audits and in coordination with investigation development. Complete investigations after referrals to law enforcement (DHCS, CMS, DOJ, or local police). Participate in hearings/appeals and testify as a witness in court proceedings. Initiate the process with L.A. Care’s Recovery Services for recoupment of overpaid monies. Submit referrals of suspected fraud cases within mandated periods required by DHCS and CMS. Prepare and submit investigative reports documenting all phases of an investigation. Compile and maintain documentation and other reporting requirements, maintaining chain of custody on all documents and following confidentiality and security guidelines. Respond to law‑enforcement requests for information and pursue applicable administrative actions during investigation/case development. Utilize data analysis techniques to detect unusual billing claims data and proactively seek out and develop leads received from fraud tips and other sources (e.g., fraud alerts, media). Participate in industry meetings and trainings, effectively sharing and gathering significant information, liaising with industry peers and law enforcement as necessary. Continuously enhance investigative skills and understanding of emerging issues and trends impacting the industry. Perform other duties as assigned. Education Required: Bachelor’s Degree in Criminal Justice or a related field. In lieu of a degree, equivalent education and/or experience may be considered. Preferred: Master’s Degree in Criminal Justice or a related field. Experience Required: Minimum of three (3) years of experience in healthcare fraud investigation/detection and/or healthcare-related specialties, including but not limited to Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental, etc. Preferred: Demonstrated investigative and/or health care expertise; experience in reviewing, analyzing/developing information, interviewing, report writing, and decision making. Skills Excellent research skills and the ability to support conclusions with documentary evidence. Strong organizational skills, managing multiple demands and priorities. Excellent verbal and written communication skills. Proficient computer skills, including MS Word and Excel. Commitment to excellence and a high regard for organizational values. 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. Training Required training details not specified. Physical Requirements Light. Additional Information No additional information provided. Salary Range Disclaimer The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change. Benefits Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO) #J-18808-Ljbffr L.A. Care Health Plan