Special Investigations Unit (SIU) Investigator – Healthcare Fraud

About the Role

The Special Investigation Unit (SIU) Investigator II serves as the journeyman-level specialist dedicated to uncovering complex fraud, waste, and abuse within our healthcare ecosystem. This role is critical to protecting our clients, members, and providers by conducting independent, objective investigations into alleged fraudulent billing and suspicious activities.

You will operate at the intersection of data analysis and legal compliance, working closely with department heads to identify vulnerabilities in Medi-Cal and Medicare policies. Your work ensures that every investigation is conducted lawfully, with a rigorous adherence to chain of custody and confidentiality standards. From analyzing claims history to testifying in court proceedings, you will be the driving force behind recouping overpaid monies and holding bad actors accountable.

Day in the Life

Your day involves a dynamic mix of deep-dive analysis and active fieldwork. You will sift through standard claims processing files to detect unusual billing patterns, utilizing data analysis techniques to proactively develop leads from fraud tips, alerts, and media sources. When necessary, you will participate in onsite audits and liaise with industry peers to stay ahead of emerging trends.

The role extends beyond the office; you may be called upon to participate in hearings, appeals, and court proceedings as a witness. You will manage a high-volume caseload, drafting executive summaries and investigative reports that document every phase of the inquiry. Whether referring cases to the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), or the Department of Justice (DOJ), you will ensure all actions are timely and compliant with mandated reporting periods.

Hiring Process

Candidates selected for this role will undergo a rigorous selection process designed to assess both investigative acumen and cultural fit. The process typically includes:

1. Initial Screening: A review of your background in healthcare fraud investigation and relevant specialty experience.
2. Technical Assessment: Evaluation of your ability to analyze complex claims data and draft investigative reports.
3. Interviews: In-depth discussions with department heads and team members regarding your approach to fraud detection and legal compliance.
4. Final Review: Verification of certifications and final hiring decision.

Our Culture & Commitment

We are committed to excellence and maintaining the highest regard for our organizational values. Our team thrives on continuous learning, with a strong emphasis on enhancing investigative skills and understanding the evolving landscape of healthcare fraud. We value diversity and believe that a wide range of perspectives strengthens our ability to detect and prevent fraud effectively.

We are an Equal Opportunity Employer and consider qualified applicants regardless of race, color, religion, sex, national origin, age, disability, genetic information, or any other protected status.