Compliance Special Investigator & Auditor

The Compliance Special Investigator & Auditor reports to the Director of Compliance & Oversight (and SVP of Compliance-Compliance Officer). This position staffs and services the Compliance Department’s Special Investigations Unit’s (“SIU”) activities to detect, investigate, and respond to (collect overpayments, and/or support necessary and required reporting and notifications) substantiated instances of Fraud, Waste, Abuse, and/or Non-Compliance. More specially, the SIU Special Investigator shall be tasked by Compliance Executive management to conduct investigations, monitoring/data mining of claims, encounters, medical management and EMR records to detect and investigate/audit internal and external operational areas, providers, vendors, and/or workforce members. This position supports the compliance program and assists in efforts to be compliant with applicable laws, regulations, and policies.

Conducts complex investigations, audits, data analytics, and reporting to detect fraud, waste, abuse, non-compliance, and policy violations. Develops corrective action plans and supports disciplinary processes. Collaborates with internal and external partners to resolve compliance issues.

Key Responsibilities:

Investigations & Audits:

Conduct investigations into reported or identified potential violations by company workforce members, operational areas, and downstream entities. Respond to queries from HPN, contracted health plans, regulatory bodies, and company legal teams regarding Fraud, Waste, Abuse, Non-Compliance, or Privacy/Security breaches. Handle duties such as interviewing individuals, conducting field visits, surveillance, completing investigative reports, and requesting/reviewing documents. Independently revise, adjust, and create new audit methodologies to align with regulatory FWA detection strategies when updates are communicated.

Case Management:

Determine case type and create an appropriate investigation plan. Complete investigations independently, ensuring the detection or verification of suspected violations of Federal, State, and/or local laws. Maintain master investigation case files.

Data Analysis:

Implement data mining of claims, payments, authorizations, and medical records to detect anomalies or compliance risks. Utilize MS-Excel for big data analysis, focusing on Compliance, Privacy & Security requirements as set by regulatory bodies.

Data Extraction:

Access and extract relevant data from internal systems, claims, payments, authorizations, and medical records databases. Work with IT teams or relevant departments to ensure smooth data retrieval processes, ensuring data integrity and security are maintained.

Data Cleaning:

Preprocess the extracted data, removing or correcting any inaccuracies or inconsistencies to ensure a high quality of data for analysis. Identify and handle missing data, outliers, and other anomalies that might skew the analysis.

Data Analysis Techniques: Utilize statistical techniques, machine learning algorithms, or other data analytics tools to identify patterns or trends. Apply techniques such as clustering, classification, regression, and anomaly detection to detect unusual patterns that might indicate fraud or abuse.

Employ visualization tools to represent data findings graphically, aiding in the understanding and presentation of complex data insights.

Risk Assessment:

Identify potential risks or vulnerabilities based on the data analysis findings. Score and rank these risks based on their potential impact, frequency, or severity to prioritize investigational efforts.

Reporting and Recommendations:

Synthesize data findings into clear, comprehensive reports, highlighting key insights, potential areas of concern, and actionable recommendations. Provide data-driven suggestions for preventive measures, corrective actions, or system enhancements to reduce future risks.

Collaboration & Reporting:

Cooperate with Federal, State, and local law enforcement agencies as needed. Create, update, and present clear and concise reports, audit findings, and materials for upper management and external audiences.

Support Director of Compliance/SVP in preparing monthly and quarterly reports for executive management and relevant compliance committees. Work closely with other departments (e.g., IT, finance, operations) to share findings, gain additional insights, and collaborate on implementing solutions or interventions. Actively engage in cross-functional team meetings, sharing data-driven insights and leveraging expertise from different domains.

Training & Monitoring:

Ensure that First Tier, Downstream, and Related Entities (FDR) and internal training sessions are conducted and completed as part of the new employee orientation and on a recurring basis.

Required Qualifications:

Proficiency in MS-Excel, particularly in handling big data.

Demonstrated experience in creating and presenting reports for both internal and external stakeholders. Knowledge of CMS/DMHC/DHCS/HPN and other health plan compliance requirements.

This position focuses on conducting Investigations into reported or identified potential areas of fraud, abuse, waste, non-compliance, and / or code of conduct violations by company workforce members, operational areas and/or its downstream entities (e.g. vendors, volunteers, contracted providers). The SIU Investigator shall specially be tasked to assist Compliance Executive Management to investigate and respond to HPN, contracted health plan, and regulatory and/or Company Legal requests to investigate or respond to queries regarding Fraud, Waste, Abuse, Non-Compliance or Privacy or Security breaches. Investigational duties shall include but not be limited to interviewing witness, conducting field visits or surveillance, and completing Special Investigative reports, case summary, witness reports, and transcripts of interviews, requesting and reviewing documents and data files.

More specifically, this position responsibilities include:

Create dashboards, visualizations, and presentations to communicate audit results and findings to leadership and governance committees

The pay range for this position at commencement of employment is expected to be between $70,304/year to  $95,000 / year; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:

• Employer-paid comprehensive medical, pharmacy, and dental for employees
• Vision insurance
• Zero co-payments for employed physician office visits
• Flexible Spending Account (FSA)
• Employer-Paid Life Insurance
• Employee Assistance Program (EAP)
• Behavioral Health Services

Savings and Retirement:

• 401k Retirement Savings Plan
• Income Protection Insurance

Other Benefits:

• Vacation Time
• Company celebrations
• Employee Assistance Program
• Employee Referral Bonus
• Tuition Reimbursement
• License Renewal CEU Cost Reimbursement Program
• Business-casual working environment
• Sick days
• Paid holidays
• Mileage

Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.