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, including performing fraud investigations and providing regular FWA reporting. The role also helps ensure appropriate procedures are in place and followed consistently to safeguard 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.

Working Conditions

• Work Environment(s): Indoor/Office
• Member/Patient Facing: No
• 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
• Ability to bend and speak clearly for at least 3 hours/day
• 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 for at least 6 hours/day
• Ability to perform repetitive finger and wrist movement for at least 3–6 hours/day
• Ability to work effectively with diverse individuals and groups

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

Knowledge, Skills and Abilities Required

• 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

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

Experience and/or Education

• Minimum 2 years’ experience in FWA, compliance and/or audit including in an operational setting within a highly regulated industry

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.

Pay

Estimated Hiring Range: $74,250.00 – $90,750.00

Bonus Target: SIP Target, 5% Annual

Benefits

• Medical, dental, vision, life, AD&D, and disability insurance
• Health Savings Account and Flexible Spending Account(s)
• Lifestyle Spending Account and 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)
• Retirement plan with employer contributions
• Paid Time Off and Paid State Sick Time based on hours worked/scheduled hours and the primary work state
• Paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility
• 401(k) contributions for non-benefits eligible employees