Career Opportunities: Special Investigations Unit Investigator (24843)

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

Job Summary

This position is responsible for administering the fraud, waste, and abuse (FWA) duties for Health Share and its affiliated lines of business. Core work includes ensuring effective measures are in place and operating effectively to prevent, detect, and correct any instances of fraud, waste, and abuse. This includes performing fraud investigations and providing regular FWA reporting. Additionally, this position helps ensure that appropriate procedures are in place and followed consistently to safeguard its assets, verify the accuracy and reliability of data, and promote efficient and effective operations.

Essential Responsibilities

• Assist in the development and operation of an effective FWA program in accordance with CMS requirements, OHA/OHP requirements, and the Federal Sentencing Guidelines with guidance from department leadership.
• Perform routine FWA investigations, audits, and corrective actions as assigned, including maintaining documents and providing routine updates; may assist senior investigator with more complex or advanced investigations.
• Prepare reports of audit findings; provide recommendations regarding improvements or corrective actions where a deficiency may exist.
• Prepare, proofread, and distribute correspondence, forms, and other information of a specialized and confidential nature.
• Respond to routine and ad hoc requests from external regulatory agencies as assigned, such as annual reviews, quarterly reports, and one-off requests.
• Prepare routine and ad hoc reports for internal and external leaders, committees, and governing body, including collecting, analyzing, and displaying data.
• Assist in developing and maintaining an organized, methodical documentation system for communicating, implementing, and administering new and existing FWA regulatory requirements.
• Review and recommend policy and procedure revisions that support the FWA/SIU program.
• Attend internal and external FWA and compliance-related meetings as assigned.
• Assist in providing effective FWA training and education to staff, both internal and external.
• Educate providers on appropriate documentation and coding.
• Participate in FWA program-related risk assessment and mitigation processes.
• Meet departmental metrics for key performance indicators.

Organizational Responsibilities

• Perform work in alignment with the organization’s mission, vision, and values.
• Support the organization’s commitment to equity, diversity, and inclusion by fostering a culture of open mindedness, cultural awareness, compassion, and respect for all individuals.
• Strive to meet annual business goals in support the organization’s strategic goals.
• Adhere to the organization’s policies, procedures, and other relevant compliance needs.

• Perform other duties as needed.

Knowledge, Skills and Abilities Required

Knowledge:

• Understanding of healthcare fraud, waste, and abuse
• Knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid
• Knowledge of investigative techniques including interviews, data analytics, evidence gathering, case documentation
• Understanding of information systems

Skills and Abilities:

• Strong research, investigative and problem-solving skills
• Strong communication skills, including written, verbal and listening skills
• Effective computer skills, including MS Office Suite
• Strong interpersonal and motivational skills
• Ability to think logically and creatively without undue influence from personal biases
• Ability to operate with a high degree of professionalism and confidentially
• Ability to plan, organize, manage, and monitor work projects
• Ability to facilitate learning opportunities in a variety of informal and formal settings
• Ability to make presentations to small and large groups
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read and hear and for at least 6 hours/day
• Ability to perform repetitive finger and wrist movement for at least 3-6 hours/day
• Ability to bend and speak clearly for at least 3 hours/day

Education and/or Experience

Required:

• Minimum 2 years’ experience in FWA, compliance and/or audit including in an operational setting within a highly regulated industry
• Fraud, waste, and abuse experience in healthcare or with health insurance.
• CPC (Certified Professional Coder) or RHIT (Registered Health Information Technician) or CFE (Certified Fraud Examiner

Working Conditions

Primary Work Environment:

☒ Indoor/Office    ☐ Member Facing    ☐ Patient Facing    ☐ Facilities/Security

Other Work Environment(s):

☒ Indoor/Office    ☐ Member Facing    ☐ Patient Facing    ☐ Facilities/Security    ☐ Outdoor Exposure

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment:  General office equipment

Travel: This position may include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

#Li-Hybrid

Health Share is an equal opportunity employer and employs personnel without regard to age, citizenship, color, creed, physical or mental disability, economic status, education, ethnicity, family responsibilities, gender identity and expression, genetic information, health status including HIV status, height, housing status, marital status, matriculation, national origin, physical appearance, race, religion, political affiliation, pregnancy, sex, sexual orientation, union membership, veteran status or other unlawful factors, with respect to recruiting, hiring, job assignment, promotion, discipline, discharge, compensation, training and other terms, conditions and privileges of employment and contracting.

Health Share is committed to creating a diverse staff made of people who are dedicated, optimistic and committed to health equity from all segments of the greater Portland Region, and we encourage people of color, people with disabilities, LGBTQ+ people, women and nonbinary people, and Veterans to apply for consideration.

Visa sponsorship is not available at this time.