Special Investigations Unit (SIU) Investigator II or III DOE

About the role

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

Responsibilities

• Perform thorough review 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 and 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 and perform case referrals to the Centers for Medicare & Medicaid (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 company policies and procedures relating to appropriateness of claims submittals, payment protocols, and other issues relating to investigations.
• Proactively pursue the detection and prevention of payment of fraudulent claims.
• Educate company employees, subscribers and providers regarding detection and prevention of health care fraud – all in service of creating a person-focused health care experience.

Qualifications

• Bachelor's Degree, Program Certification (i.e. Fraud Examiner or Criminal Justice), or successful completion of law enforcement academy, with two years of job related experience or equivalent combination of education and work related experience.
• Certified Professional Coder (CPC) certification preferred.
• Experience with CMS and HHS-OIG/FBI or similar agencies preferred.
• Current RN or LPN licensure preferred.

Skills and Attributes

• Extensive knowledge of medical procedures, terminology, and investigations, with experience in third party payer or independent health services contracting desired, along with investigative skills and exposure to the criminal justice system.
• Proficient with Microsoft Office software programs and demonstrated ability to handle confidential information, multiple tasks, and work independently with minimal supervision while functioning within corporate structure.
• Excellent written, oral and interpersonal communication skills with proven ability to coordinate activities diplomatically and persuasively across varying levels of management, staff, external agencies and medical professionals.
• Strong analytical, organizational and problem-solving abilities with 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.
• Must have personal, reliable transportation, valid driver's license and proof of automobile insurance for on-site audits and investigations, with ability to work flexible schedules to accommodate investigation needs.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

Pay

• Oregon, Washington, Utah, and Idaho: The expected hiring range is $57,800 - $78,200, the full salary range is $54,000 - $89,000 and the bonus target is 5%.
• Oregon, Washington, Utah, and Idaho: The expected hiring range is $62,900 - $85,100, the full salary range is $59,000 - $97,000 and the bonus target is 10%.