L.A. Care Health Plan · 2 days ago
Special Investigation Unit Clinical Healthcare Fraud Investigator III
Los Angeles, CA
Full-time
Onsite
Mid, Senior Level
$89K/yr - $142K/yr
7+ years expL.A. Care Health Plan is the nation’s largest publicly operated health plan, created to provide health coverage to low-income Los Angeles County residents. The Special Investigation Unit Clinical Healthcare Fraud Investigator III leads complex investigations into suspected healthcare fraud, waste, and abuse, managing full-cycle investigations and collaborating cross-functionally to ensure compliance with federal and state mandates.
FitnessGovernmentHealth Care
Responsibilities
Conducts complex clinical investigations involving provider, member, or vendor misconduct, including the review of claims, clinical documentation, and billing practices
Conducts interviews, collects and preserves evidence, and maintains proper chain of custody
Coordinates with law enforcement, regulatory agencies, and internal partners on referrals and case collaboration
Collaborates closely with Compliance, Payment Integrity, and Legal Affairs to ensure effective oversight and timely resolution of potential fraud, waste, and abuse matters
Analyzes patterns and emerging schemes such as pill-mill activity, upcoding, unbundling, ghost and double billing, and credentialing fraud
Prepares comprehensive investigative reports and referral packets that meet the evidentiary and procedural standards of the Centers for Medicare & Medicaid Services (CMS) and the California Department of Health Care Services (DHCS)
Supports recovery efforts by identifying overpayments and recommending cost-avoidance strategies
Mentors’ junior investigators, sharing best practices in case methodology and documentation standards
Contributes to the enhancement of detection controls and analytic queries to strengthen proactive oversight
Participates in interdisciplinary task forces focused on emerging risks such as telehealth abuse, pharmacy diversion, and durable medical equipment (DME) fraud
Apply subject matter expertise in evaluating business operations and processes
Identify areas where technical solutions would improve business performance
Consult across business operations, provide mentorship, and contribute specialized knowledge
Ensure that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices
Provide training and recommend process improvements as needed
Performs other duties as assigned
Qualification
Required
Bachelor's Degree in Nursing or Related Field
At least 4 years of experience as a practicing clinician (e.g., nursing, pharmacy, or medical practice)
At least 3 years conducting healthcare fraud investigations, including experience managing complex cases through full lifecycle
Expertise in clinical documentation review, managed care operations, and regulatory compliance
Strong understanding of coding and reimbursement structures (including Current Procedural Terminology (CPT), Healthcare Common Procedure Coding Systems (HCPCS), International Classification of Diseases (ICD-10)), medical billing, and claims review processes
Working knowledge of program-integrity requirements under 42 CFR 438.608, CMS Chapter 21, and applicable state regulations
Proficiency with Microsoft Office suite and investigative documentation systems
Demonstrated proficiency with data analytics and visualization tools (e.g., Tableau, Excel Power Query, or Power BI)
Strong collaboration skills
Excellent communication and report-writing skills suitable for internal and external stakeholders
Excellent written, verbal, and presentation skills suitable for executive and regulatory audiences
Ability to read, interpret and draw accurate conclusions from legal and factual information and synthesize findings in clear, professional reports
Strong working knowledge of federal and state program-integrity regulations
Demonstrated expertise in clinical documentation review, regulatory compliance, and managed-care operations
Proven ability to mentor others and manage multiple investigations concurrently
Capacity to prioritize competing demands, meet strict regulatory deadlines, and manage multiple investigations simultaneously
Active, current, and unrestricted California Clinical License commensurate with clinical degree
Preferred
Master's Degree in Public Health or Related Field
Prior experience in a Special Investigations Unit (SIU) or payment-integrity environment
Familiarity with healthcare operational systems and processes
Current knowledge of emerging fraud, waste, and abuse (FWA) schemes and industry countermeasures
Working knowledge and understanding of relevant state and federal statutes and the ability to interpret their operational impact
Certified Fraud Examiner (CFE)
Accredited Health Care Fraud Investigator (AHFI)
Certified HealthCare Compliance (CHC)
Lean Six Sigma Green Belt
Lean Six Sigma Black Belt
Benefits
Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)
Company
L.A. Care Health Plan
L.A. Care’s mission is to provide access to quality health care for L.A.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Melanie Rainer
Chief Strategy and Transformation Officer
Recent News
2026-01-17
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2025-08-27
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