Investigator - Special Investigation Unit

Role: Investigator - Special Investigation Unit
Location: Beaverton, OR
Type: FTE/Permanent

Job Description:

• Support timely completion of compliance related audits and investigations of the Special Investigations Unit (SIU).
• Collaborate with and learn from subject matter experts to identify, investigate and correct fraudulent and/or abusive billing and coding practices, which may advance in complexity with experience
• Leverage credible sources of information from Internet research in case preparation
• Proactively learns and applies data analysis related to fraud risk identification and prevention
• Able to manage a workload with multiple cases and audits simultaneously
• May assist Senior Investigator or SIU Director in developing, implementing and performing compliance related auditing and monitoring activities.
• Coordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices; keeps organized audit work papers that enables collaboration with external teams in the audit and recovery process
• Coordinate with parties with compliance accountabilities to facilitate corrective action completion and behavior change
• Provide education related to coding, medical record documentation requirements, healthcare compliance and fraud, waste and abuse to staff, vendors and contracted providers/facilities
• Support team in peer review and delivery of quality work product, including integrating checks on their own work product
• Presents on fraud risk in a professional manner, in written and oral reports, tailored to providers, executives, members, and regulators
• Submit timely and professional reports of case findings to regulators, law enforcement, and internal business partners
• Provide training on fraud prevention to executives, caregivers, business partners, and members
• Supports timely processing of risk report intake triage, timely processing of prepay audit claims, and other compliance requirements

Required qualifications:

• Bachelor's Degree -OR- a combination of equivalent education and experience
• 5+ years coding experience at a healthcare provider, facility or health insurance company
• 2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility or other relevant healthcare environment
• Project management experience, education program development experience and group presentation experience
• Experience in use of data mining software/tools

Preferred qualifications:

• Clinical background such as Registered Nurse (RN), Doctorate of Medicine (MD), or Doctor of Chiropractic (DC)
• Current certification as Certified Coding Professional (CPC)
• Current certification in health care fraud investigation, such as Accredited Healthcare Fraud Investigator (AHFI), Certification as an Internal Auditor (CIA), Healthcare Compliance certification (CHC), or equivalent
• Certification in Project Management or Agile (PMP, CSM, CSPO)
• Basic understanding of statistics and data analytics
• Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software
• Advanced understanding of MS Excel and PowerPoint
• Professional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc.