Special Investigation Unit Investigator II

Special Investigation Unit Investigator II Los Angeles, CA (Remote) 4-Month Contract JPC - 20366 Solugenix is assisting a client, a prestigious health insurance company, in their search for a Special Investigation Unit Investigator II. This is a 4-month contract opportunity based out of Los Angeles, CA (Remote). The Special Investigation Unit Investigator II is the 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 the client, members, and providers. The position works closely with the department heads on potential fraud, waste, and abuse areas. This position ensures 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. Qualifications: Bachelors Degree - Criminal Justice and/or Accounting. In lieu of degree, equivalent education and/or experience may be considered. Minimum of 3 years of experience in healthcare fraud investigation/detection and/or healthcare related specialty including but not limited to; Pharmacy, DME, Mental Health, Behavioral Health, Hospice, Home Health, Dental etc. Excellent research skills and the ability to support conclusions with documentary evidence. Demonstrated strong organizational skills and the ability to manage multiple demands and priorities. Excellent and effective communication skills, both verbal and written. Proficient in computer skills, including computer applications such as MS Word and Excel. Understanding of the vital importance of commitment to excellence and demonstrating a high regard for organizational values. Preferred: Demonstrated investigative and/or health care expertise. Experienced in reviewing, analyzing/developing information to include interviewing, report writing, and decision making. Responsibilities: Conducts complex independent investigations resulting from the discovery of suspicious claims or incidents involving the client, members, and service providers that could potentially involve fraud, waste, or abuse. Reviews information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and detect potential fraudulent or abusive billing practices or vulnerabilities in Medi-Cal/Medicare policies, and initiates appropriate action. Participates in onsite audits as assigned in conjunction with investigation development. Completes investigation after referrals to law enforcement (Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), Department of Justice (DOJ) or local police). Participates at hearings/appeals and can testify as a witness in court proceedings. Initiates the process with the client's Recovery Services for the recoupment of overpaid monies. Submits referrals of suspected fraud cases within the mandated period of time as required by DHCS and CMS. Prepares and submits investigative report documenting all phases of an investigation. Compiles and maintains various documentation and other reporting requirements. Maintains chain of custody on all documents and follows all confidentiality and security guidelines. Maintains cases referred to law enforcement and responds to requests for information; pursues applicable administrative actions during investigation/case development. Utilizes data analysis techniques to detect unusual billing claims data and proactively seeks out and develops leads received from fraud tips and any variety of sources (e.g., fraud alerts, media). Participates in industry meetings/trainings and is able to effectively share and gather significant information. Able to liaison with industry peers, and where necessary, interface appropriately with law enforcement. Continually enhances investigative skills and understanding of emerging issues and trends impacting the industry. Performs other duties as assigned. Licenses/Certifications: Certified Fraud Examiner (CFE) or willingness to obtain the AHFI certification. Accredited Health Care Fraud Investigator (AHFI) Certified Professional Coder (CPC) Pay Range for CA, CO, IL, NJ, NY, WA, and DC: $43.29/hour to $48.29/hour. Starting rate of pay offered may vary depending on factors including but not limited to, position offered, location, education, training, and/or experience. Solugenix will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act and Ordinance. Applicants do not need to disclose their criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if we are concerned about conviction that is directly related to the job, applicants will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report. About the Client Our client is one of the world's leading health insurance companies based out of Los Angeles, CA. About Solugenix Solugenix is a leader in IT services, delivering cutting-edge technology solutions, exceptional talent, and managed services to global enterprises. With extensive expertise in highly regulated and complex industries, we are a trusted partner for integrating advanced technologies with streamlined processes. Our solutions drive growth, foster innovation, and ensure compliance-providing clients with reliability and a strong competitive edge. Recognized as a 2024 Top Workplace, Solugenix is proud of its inclusive culture and unwavering commitment to excellence. Our recent expansion, with new offices in the Dominican Republic, Jakarta, and the Philippines, underscores our growing global presence and ability to offer world-class technology solutions. Partnering with Solugenix means more than just business-it means having a dedicated ally focused on your success in today's fast-evolving digital world.