Special Investigation Unit Clinical Healthcare Fraud Investigator III

Salary Range: $88,854.00 (Min.) - $ (Mid.) - $ (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.

The Special Investigation Unit Clinical Healthcare Fraud Investigator III leads complex investigations into suspected healthcare fraud, waste, and abuse across all of L.A. Care’s lines of business. This position independently manages full‑cycle investigations from intake through closure, develops investigative strategies, prepares evidentiary packages for regulatory or law enforcement referral, and provides clinical and operational insight into healthcare billing patterns and provider behaviors.

This position collaborates cross‑functionally to safeguard organizational integrity and ensure compliance with federal and state program‑integrity mandates by using advanced clinical judgment and regulatory knowledge. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.

• Conduct complex clinical investigations involving provider, member, or vendor misconduct, including the review of claims, clinical documentation, and billing practices.
• Conduct interviews, collect and preserve evidence, and maintain proper chain of custody.
• Coordinate with law enforcement, regulatory agencies, and internal partners on referrals and case collaboration. Collaborate closely with Compliance, Payment Integrity, and Legal Affairs to ensure effective oversight and timely resolution of potential fraud, waste, and abuse matters.
• Analyze patterns and emerging schemes such as pill‑mill activity, upcoding, unbundling, ghost and double billing, and credentialing fraud.
• Prepare 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).
• Support recovery efforts by identifying over payments and recommending cost‑avoidance strategies.
• Mentor junior investigators, sharing best practices in case methodology and documentation standards.
• Contribute to the enhancement of detection controls and analytic queries to strengthen proactive oversight.
• Participate 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 performance, and consult across business operations.
• Provide training and recommend process improvements as needed.
• Perform other duties as assigned.

Required: Bachelor's Degree in Nursing or Related Field (in lieu of degree, equivalent education and/or experience may be considered)

Preferred: Master’s Degree in Public Health 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.
• Prior experience in a Special Investigations Unit (SIU) or payment‑integrity environment (preferred).

• Expertise in clinical documentation review, managed care operations, and regulatory compliance.
• Strong understanding of coding and reimbursement structures (CPT, HCPCS, 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,…