Special Investigation Unit Investigative Analyst III

Job description

Special Investigation Unit Investigative Analyst III

nJob Category: Administrative, HR, Business Professionals

nDepartment: Special Investigations Unit

nLocation:

nLos Angeles, CA, US, 90017

nPosition Type: Full Time

nRequisition ID: 13309

nSalary Range: $67,186.00 (Min.) - $87,342.00 (Mid.) - $107,498.00 (Max.)

nEstablished 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.

nMission: 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.

nJob Summary

nThe 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.

nThe 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.

nThe 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.

nDuties

nOversees 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.

nEnsures Federal and State regulatory reports (CMS and DHCS) are submitted onetime, within the 10-day reporting period.

nServes 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.

nEvaluates investigative leads and determines if the need exists to distribute these leads to PP or PPGs.

nUses 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.

nPrepares clear and concise investigative reports to support analytical findings, recommendations, and actions.

nAs a Subject Matter Expert, develops and conducts training on unit processes, for lower-tiered positions.

nPerforms other duties as assigned.

nDuties Continued

nEducation Required

nAssociate's Degree

nIn lieu of degree, equivalent education and/or experience may be considered.

nEducation Preferred

nBachelor's Degree

nExperience

nRequired:

nMinimum of 4 years of experience in healthcare fraud investigation/ detection.

nPreferred:

nExperience in CA Medi-Cal/ Medicare/ Medicaid Services Payment Services.

nSkills

nRequired:

nStrong project leadership skills; ability to prioritize, plan and handle multiple tasks/demands simultaneously.

nAbility to support heavy workload volume and meet critical regulatory guidelines.

nUnderstanding of Federal and State healthcare fraud regulatory reporting requirements.

nStrong understanding of HCFS and HPMS.

nUnderstanding of healthcare operational systems and processes.

nStrong understanding of Accurint, MS Excel, Word, PowerPoint, SharePoint.

nAbility to navigate and master L.A. Care proprietary software programs.

nExcellent verbal and written communication skills.

nStrong knowledge of standard industry coding guides such as CPT, HCPCS, ICD-10 CMS 1500 and UB04 data elements.

nKnowledge of the Healthcare Fraud Shield Case Management system.

nKnowledge of state and federal laws and ability to interpret and take action on the aspects of such laws that impact the business.

nLicenses/Certifications Required

nLicenses/Certifications Preferred

nCertified Medical Coder

nAccredited Health Care Fraud Investigator (AHFI)

nRequired Training

nPhysical Requirements

nLight

nAdditional Information

nSalary 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.

nL.A. Care offers a wide range of benefits including

nnnPaid Time Off (PTO)

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nnTuition Reimbursement

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nnRetirement Plans

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nnMedical, Dental and Vision

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nnWellness Program

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nnVolunteer Time Off (VTO)

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Worksite address

los angeles, CA, 90079, US

Who can apply

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