Special Investigations Unit (SIU) Investigator II or III DOE

Hybrid role (3 days/week in office) at our Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, or Lewiston offices. Candidates must reside within commutable distance of that location or be willing to relocate.

About the role

Join our Cause to create a person-focused and economically sustainable health care system. As a member of the Special Investigations Unit, our SIU Investigator conducts investigations into allegations of fraud and abuse. This role bridges complex fraud detection with education to prevent health care fraud, ensuring every healthcare dollar is spent appropriately.

Responsibilities

• Perform thorough reviews of available data, intelligence, evidence, and open-source information.
• Conduct onsite, prepayment, and desk audits.
• Provide investigative support in pursuing recovery of inappropriate and/or insupportable claims.
• Formulate audit and investigative reports; identify and document funds to be recovered and returned to the company.
• Conduct interviews and navigate contentious interactions calmly and professionally.
• Identify and document evidence and intelligence to support case referrals to CMS, HHS-OIG, OPM-OIG, or other investigative agencies for administrative or criminal action.
• Serve as a liaison between the Special Investigations Unit and other company departments regarding policies and procedures related to claims submittals, payment protocols, and investigations.
• Proactively detect and prevent payment of fraudulent claims.
• Educate company employees, subscribers, and providers on detecting and preventing health care fraud.
• Receive, analyze, and coordinate fraud and abuse complaints from internal and external sources, then conduct moderately complex investigations.
• Provide accurate accounting of recovered funds from audit activities, criminal or civil convictions, and settlements.
• Maintain continuing education through anti-fraud and legal issue seminars; hold at least one professional credential (e.g., CPC).
• Review pertinent articles and regulatory requirements; provide post-audit education to providers and train new Investigators and employees on detecting fraudulent billing practices.
• Assist with maintenance of audit and investigation files, formulation of company policies addressing loss exposures, and maintain contact with the provider community in both educational and investigative roles.
• Issue audit findings and prepayment claim determinations; maintain clear documentation and professional judgment to support them independently.
• Represent the company at external and internal meetings on fraud and abuse issues; testify in court as required.
• Develop professional relationships with associations and agencies for detection of local and national fraud schemes.
• Conduct witness and target interviews; analyze evidence; examine records for authenticity; prepare and evaluate investigation reports.
• Provide information for affidavit preparation; maintain communications with law enforcement and regulatory agencies to present case findings.

Requirements

• Bachelor’s Degree, Program Certification (e.g., Fraud Examiner or Criminal Justice), or successful completion of a law enforcement academy, with two years of job-related experience or equivalent combination of education and experience.
• Certified Professional Coder (CPC) certification preferred.
• Experience with CMS, HHS-OIG/FBI, or similar agencies preferred.
• Current RN or LPN licensure preferred.
• Extensive knowledge of medical procedures, terminology, and investigations; experience in third-party payer or independent health services contracting desired.
• Proficient with Microsoft Office software; ability to handle confidential information, multitask, and work independently with minimal supervision.
• Excellent written, oral, and interpersonal communication skills; ability to coordinate activities diplomatically across varying levels of management, staff, external agencies, and medical professionals.
• Strong analytical, organizational, and problem-solving abilities; demonstrated maturity, tact, and composure in stressful or confrontational situations.
• Knowledge of state codes and regulations pertaining to health care and insurance industries, including legal terminology and procedures.
• Personal, reliable transportation; valid driver’s license; proof of automobile insurance for on-site audits and investigations; ability to work flexible schedules.
• Experience with AI tools and technologies to enhance productivity and decision-making highly desired.

Pay

Pay ranges vary based on the candidate's work location, skills, experience, education, training, licensure/certifications, and performance history.

• Special Investigations Unit (SIU) Investigator II (Oregon, Washington, Utah, Idaho):
  • Expected hiring range: $57,800 - $78,200
  • Full salary range: $54,000 - $89,000
  • Bonus target: 5%
• Special Investigations Unit (SIU) Investigator III (Oregon, Washington, Utah, Idaho):
  • Expected hiring range: $62,900 - $85,100
  • Full salary range: $59,000 - $97,000
  • Bonus target: 10%

Benefits

• Medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure, plus 10 company-paid holidays.
• Market-leading 401(k) with a significant company match; potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental leave (eligibility requires 12 months of continuous service).
• Award-winning wellness programs with participation rewards.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

Work-from-home options are available for most roles, requiring a wired internet connection (not satellite or cellular) with a minimum upload speed of 5Mb and download speed of 10Mb. New hires must have access to a personal mobile device for Multi-Factor Authentication (MFA).

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation with over 100 years of history. Our caring and supportive colleagues innovate toward sustainable, person-focused health care. Benefits include:

• Working alongside diverse teams building cutting-edge solutions.
• Competitive salary and generous benefits.
• Career growth with a company committed to your success.
• Community outreach programs.
• Employee resource groups for connecting with colleagues.