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

• Assist 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.
• 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.

Qualifications

• Minimum 2 years' experience in FWA, compliance and/or audit including in an operational setting within a highly regulated industry.
• 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.
• Understanding of healthcare fraud, waste, and abuse.
• Understanding the difference between State Medicaid programs and Medicare.
• 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.

Preferred qualifications

• Oregon Medicaid experience or health plan experience.
• CPC (Certified Professional Coder) or RHIT (Registered Health Information Technician) or CFE (Certified Fraud Examiner).

Pay

Estimated hiring range: $74,250.00 - $90,750.00. Bonus target: SIP Target, 5% Annual.