Provider Fraud Investigator 3 (I3/DAIO)

State of Washington•Thurston County – Olympia, WA

2d•Remote

About The Position

The Washington State Health Care Authority’s Special Investigations Unit (SIU), within the Division of Audit, Integrity, and Oversight (DAIO), is seeking a Provider Fraud Investigator 3 to investigate allegations of provider fraud in Washington’s Medicaid program. The role protects Apple Health and public funds by determining whether allegations are credible, developing cases from intake through resolution, and coordinating with the Attorney General’s Medicaid Fraud and Abuse Division, managed care organizations, and state and federal partners. The investigator independently designs investigative strategies, evaluates complaints and referrals, manages case assignments, supports civil and criminal investigations, and communicates findings through reports, memorandums, and presentations. The position also reviews managed care entity fraud deliverables, participates in allegation and de-confliction meetings, and coordinates investigative efforts across agencies. This is a full-time, permanent, remote position requiring Washington State residency by the first day of employment. Employees must report to the Olympia office on their first and final employment days. Occasional in-person meetings, travel, and field visits may be required. The standard schedule is Monday through Friday, 8 a.m. to 5 p.m.; alternative schedules may be considered based on business needs and supervisor approval.

Requirements

Deep, fluent knowledge of federal regulations and sub-regulatory guidance, state laws, agency policies and rules, and managed care contracts.
Thorough understanding of credible allegations of fraud and the legal thresholds for referring cases to the Attorney General’s Medicaid Fraud Control Division.
Demonstrated competency in high-stakes administrative actions, including initiating payment suspensions and coordinating joint civil and criminal investigations.
Demonstrated ability to independently formulate, adapt, and carry out complex investigative plans.
Demonstrated understanding of full-lifecycle management of complex cases, from intake through final resolution and reporting.
Proficiency in planning and conducting secure, objective onsite investigations of provider facilities or managed care entities.
Advanced ability to query, analyze, and mine complex claims data, billing codes, and encounter records to identify anomalous or potentially fraudulent billing patterns.
Ability to objectively review provider billing records, electronic health records, and managed care financial records, and collaborate with clinical staff to synthesize technical medical evidence.
Demonstrated ability to identify systemic policy gaps or IT vulnerabilities associated with fraudulent practices.
Advanced interviewing skills for engaging diverse audiences, including medical providers, corporate executives, provider staff, and Apple Health clients.
Commitment to professional objectivity and basing findings on verifiable facts and gathered evidence.
Ability to assess the credibility of fraud indicators, including through managed care organization allegation reviews.
Competency in mitigating cross-contamination across networks when investigating fraud alerts.
Ability to prepare formal investigative reports, legal memorandums, and case presentations for stakeholders, agency leadership, and prosecutors.
Ability to apply an equity lens to decisions, processes, and day-to-day work.
Ability to learn and grow by seeking new perspectives, learning from experience, and continuously improving work and service.
Ability to meet the needs of others by listening, understanding different perspectives, and responding with care, respect, and appropriate solutions.

Nice To Haves

Professional experience as a Medical Assistant Program Specialist 1, Health Care Program Consultant, or Medical Assistance Specialist 4 or 5.
Work experience auditing or reviewing healthcare claims, such as claims for licensed professionals, pharmacy, durable medical equipment, ambulance, behavioral health, home health services, or nursing home services.
Working knowledge of medical terminology and the ability to interpret healthcare documentation.
Experience in data mining, data interpretation, and data analysis.
Experience conducting medical record reviews and applying federal and state regulations, coding rules, and billing requirements.
Proficiency in ICD-10, CPT, and HCPCS coding principles.
Proficiency with Microsoft Word, Excel, and Access.
Ability to lead teams and build consensus.
Knowledge of ProviderOne or another Medicaid Management Information System (MMIS).
Knowledge of healthcare auditing concepts and principles.
Advanced degree in public health, public administration, social work, or a closely related field.

Responsibilities

Maintain expert knowledge of federal regulations and guidance, state laws and regulations, agency policies and rules, contracts, and other relevant criteria.
Design and implement investigative strategies, using independent judgment to plan and direct complex investigations.
Research and investigate leads, complaints, and referrals received through the Agency’s Hot Tips platform or other referral sources.
Manage assigned cases throughout their full lifecycle, from intake through resolution and reporting.
Refer credible fraud allegations to the Attorney General’s Medicaid Fraud and Abuse Division for civil and criminal investigation and prosecution.
Support fraud investigations conducted by the Medicaid Fraud and Abuse Division.
Initiate payment suspension protocols when the Medicaid Fraud and Abuse Division accepts a credible allegation of fraud referral.
Communicate investigation results to appropriate stakeholders through formal and informal reports, memorandums, and case presentations.
Review managed care entity allegation and fraud referral deliverables.
Facilitate managed care organization allegation meetings to assess whether allegations appear credible.
Attend de-confliction meetings to ensure active fraud cases are known to DAIO.
Participate in bimonthly FACT meetings to coordinate cases and leads.
Participate in multi-agency coordination of fraud investigations with partners that may include the Medicaid Fraud and Abuse Division, managed care organizations, the Department of Health, the Department of Social and Health Services, HHS-OIG, and the FBI.
Plan and conduct secure, objective onsite investigations of provider facilities or managed care entities.
Analyze claims data, billing codes, encounter records, provider billing and health records, and managed care financial records to evaluate evidence and identify potential fraud patterns.
Collaborate with clinical staff to assess technical medical evidence.
Identify systemic policy gaps or information technology vulnerabilities that may enable fraudulent practices.
Conduct interviews with providers, corporate executives, provider staff, and program clients.
Manage fraud alerts across networks, including notifying other managed care organizations and shifting investigative focus to fee-for-service billing when appropriate.