Special Investigations Unit Investigator

About the role

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.

Responsibilities

• Aid in the development and operation of an effective FWA program in accordance with CMS requirements, OHA/OHP requirements, and applicable laws 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.
• Aid 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.
• Aid 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.

Requirements

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

Qualifications

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 confidentiality
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
Knowledge of healthcare fraud, waste, and abuse
Understanding of the difference between State Medicaid programs and Medicare
Knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid
Understanding 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 confidentiality
• 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

Benefits

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package. Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, employee assistance program, wellness program, discounts, and multiple supplemental benefits (e.g., voluntary life, critical illness, accident, hospital indemnity, identity theft protection, pre-tax parking, pet insurance, 529 College Savings, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

Organization

The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.