SIU Investigator

An SIU Investigator at LA Care is responsible for investigating suspected healthcare fraud, waste, and abuse across providers, members, and claims. They analyze billing data, gather evidence, conduct interviews, and build detailed case reports to determine if fraudulent activity occurred. The role also involves working with regulatory agencies and law enforcement, including submitting cases and supporting legal actions when needed. Overall, they own the full investigation process end-to-end while ensuring all work is accurate, compliant, and well-documented.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.

Core Responsibilities:
Investigations
• Conduct end-to-end investigations into suspected fraud involving providers, members, and claims
• Analyze claims data, billing patterns, and system records to identify suspicious activity
• Gather evidence, perform interviews, and produce detailed investigative reports

Regulatory & Legal
• Submit fraud referrals to CMS, DHCS, and law enforcement within required timelines
• Support investigations with external agencies (DOJ, FBI, local law enforcement)
• Participate in hearings/appeals and provide testimony when required
• Initiate recovery of overpayments and support case development

Audit & Compliance
• Participate in onsite audits and ensure investigations meet legal and compliance standards
• Maintain documentation, chain of custody, and confidentiality requirements
• Identify vulnerabilities in Medi-Cal/Medicare processes and recommend actions

Data & Lead Development
• Use data analysis to detect unusual billing patterns and fraud indicators
• Develop investigative leads from tips, alerts, and external sources

Collaboration & Development
• Liaise with internal teams, industry peers, and law enforcement
• Participate in trainings and stay current on emerging fraud trends

Education: Bachelor’s required (Criminal Justice, Accounting, or related); Master’s preferred
Experience:
• 3+ years in healthcare fraud investigations or related specialty
• Experience with investigations, report writing, and data analysis preferred

Skills
• Strong analytical, research, and investigative skills
• Excellent communication (written & verbal)
• Ability to manage multiple cases and priorities
• Proficiency in Excel and Word
• Strong attention to detail and compliance mindset

Certifications (Preferred)
• CFE, AHFI, or CPC

Bottom Line
Independently investigates suspected fraud cases, leveraging data and evidence to support compliant, well-documented outcomes and regulatory actions.

Benefit packages for this role will start on the 1st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.