Special Investigations Unit Investigator

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Estimated Hiring Range:

Bonus Target:

Current CareOregon Employees: Please use the internal Workday site to submit an application for this job.

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Essential Responsibilities

• Assist in the development and operation of an effective FWA program in accordance with CMS requirements, OHA/OHP requirements, and the Federal Sentencing Guidelines 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.

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.

Experience and/or Education

Required

• Minimum 2 years’ experience in FWA, compliance and/or audit including in an operational setting within a highly regulated industry
• CPC (Certified Professional Coder) or RHIT (Registered Health Information Technician) or CFE (Certified Fraud Examiner

Preferred

• Fraud, waste, and abuse experience in healthcare or with health insurance

Knowledge, Skills and Abilities Required

Knowledge

• Understanding of healthcare fraud, waste, and abuse
• 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

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 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

• Ability to work effectively with diverse individuals and groups

• 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 and for at least 6 hours/day
• Ability to perform repetitive finger and wrist movement for at least 3-6 hours/day

• Ability to bend and speak clearly for at least 3 hours/day

Working Conditions

Work Environment(s):        ☒ Indoor/Office    ☐ Community      ☐ Facilities/Security     ☐ Outdoor Exposure

Member/Patient Facing:    ☒ No                          ☐ Telephonic        ☐ In Person

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

We offer a strong Total Rewards Program. This includes competitive pay, bonus opportunity, and a comprehensive benefits package.  Eligibility for bonuses and benefits is dependent on factors such as the position type and the number of scheduled weekly hours. Benefits-eligible employees qualify for benefits beginning on the first of the month on or after their start date. CareOregon offers medical, dental, vision, life, AD&D, and disability insurance, as well as health savings account, flexible spending account(s), lifestyle spending account, 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, etc.). We also offer a strong retirement plan with employer contributions. Benefits-eligible employees accrue PTO and Paid State Sick Time based on hours worked/scheduled hours and the primary work state. Employees may also receive paid holidays, volunteer time, jury duty, bereavement leave, and more, depending on eligibility. Non-benefits eligible employees can enjoy 401(k) contributions, Paid State Sick Time, wellness and employee assistance program benefits, and other perks. Please contact your recruiter for more information.

We are an equal opportunity employer

CareOregon is an equal opportunity employer.  The organization selects the best individual for the job based upon job related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status or disability. The organization will make a reasonable accommodation to known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation will impose an undue hardship on the operation of our organization.