Special Investigation Unit Investigative Analyst III

Job Category: Administrative, HR, Business Professionals Department: Special Investigations Unit Location: Los Angeles, CA, US, 90017 Position Type: Full Time Salary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (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 (SIU) Investigative Analyst III is responsible for overseeing the initial intake and regulatory reporting of all source investigative leads. The SIU Analyst III triages all investigative leads including hotline complaints, e-mail reports, referrals from the Credentialing Department, referrals from Law Enforcement and referrals from Federal and State regulatory agencies. This includes review of the investigative lead and entering the complaint information into the Health Care Fraud Shield (HCFS) case management data system and the preparation of the Federal and State regulatory reports. This position ensures that these regulatory reports are submitted onetime, within the 10-day reporting period. The SIU Analyst III serves as the point of contact with the Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS). This position takes the lead in developing the reporting functions of HCFS and maintains regular contact with HCFS on issues relating to the development and reconstruction of the HCFS reporting system. This position also is responsible for analyzing all new case leads to determine if Planned Partners (PPs) or Professional Provider Groups (PPGs) require notification. If the PP/PPGs have an investigative jurisdiction, the SIU Analyst III ensures the proper CMS and DHCS reports are sent to the agencies in a timely manner. The SIU Investigative Analyst III oversees data analysis in support of ongoing Investigative matters and assists SIU Investigators in the development of reporting for complex health care fraud investigations. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties: Oversees the initial intake, triage and regulatory reporting of all investigative leads including hotline complaints, e-mail reports, referrals from the Credentialing Department, referrals from Law Enforcement and referrals from Federal and State regulatory agencies. Ensures Federal and State regulatory reports (CMS and DHCS) are submitted onetime, within the 10-day reporting period. Serves as a Subject Matter Expert (SME) on the HCFS Data system and is the point of contact to HCFS on matters of system updates regarding the development and updates of the HCFS reporting system. Evaluates investigative leads and determines if the need exists to distribute these leads to PP or PPGs. Uses knowledge of healthcare coding conventions, fraud schemes, and general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data, provider enrollment data, and other sources. Prepares clear and concise investigative reports to support analytical findings, recommendations, and actions. As a Subject Matter Expert, develops and conducts training on unit processes, for lower-tiered positions. Performs other duties as assigned.

Duties: Continued Education Required Associate's Degree In lieu of degree, equivalent education and/or experience may be considered. Education Preferred Bachelor's Degree Experience Required: Minimum of 4 years of experience in healthcare fraud investigation/ detection.

Preferred: Experience in CA Medi-Cal/ Medicare/ Medicaid Services Payment Services.

Skills Required: Strong project leadership skills; ability to prioritize, plan and handle multiple tasks/demands simultaneously. Ability to support heavy workload volume and meet critical regulatory guidelines. Understanding of Federal and State healthcare fraud regulatory reporting requirements. Strong understanding of HCFS and HPMS. Understanding of healthcare operational systems and processes. Strong understanding of Accurint, MS Excel, Word, PowerPoint, SharePoint. Ability to navigate and master L.A. Care proprietary software programs. Excellent verbal and written communication skills. Strong knowledge of standard industry coding guides such as CPT, HCPCS, ICD-10 CMS 1500 and UB04 data elements. Knowledge of the Healthcare Fraud Shield Case Management system. Knowledge of state and federal laws and ability to interpret and take action on the aspects of such laws that impact the business. Licenses/Certifications Required Licenses/Certifications Preferred Certified Medical Coder Accredited Health Care Fraud Investigator (AHFI) Required Training Physical Requirements Light Additional Information 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. L.A. Care offers a wide range of benefits including Paid Time Off (PTO) Tuition Reimbursement Retirement Plans Medical, Dental and Vision Wellness Program Volunteer Time Off (VTO)