Career Opportunities: Special Investigations Unit Investigator (24867)

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 CareOregon 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 repor
• 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.
• and one-off requests.
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• 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 of the organization’s strategic goals.
• Adhere to the organization’s policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

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

Preferred

• Fraud, waste, and abuse experience in healthcare or with health insurance

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

Working Conditions

Work Environment(s):   ☒ Indoor/Office    ☐ Community      ☐ Facilities/Security     ☐ Outdoor Exposure

Member/Patient Facing:    ☒ No                          ☐ Telephonic        ☐ In Person

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

Equipment:  General office equipment

Travel: 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.

Work Location: Work from home

#MULTI

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

Veterans are strongly encouraged to apply.

We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

Visa sponsorship is not available at this time.