Senior Investigator

PacificSource • Portland, OR

1d • Onsite

About The Position

The Senior Investigator manages work related to fraud, waste and abuse audits and investigations across several independent and specialized teams. Functions include, conducting in depth investigations making decisions and recommendations on case direction, scope and timing; collaborating with managers and staff in Claims, Provider Network, Appeals and Grievances, Finance, Utilization Management and Analytics throughout the audit lifecycle; ensuring audit compliance with state and federal laws and regulations, contract requirements and company policies and procedures as they pertain to fraud, waste and abuse.

Requirements

• Minimum of 4 years of experience conducting complex healthcare fraud investigations required.
• Significant experience in facilitating audit activities across specialized teams required.
• Ability to effectively and professionally communicate with internal and external stakeholders, in both written and verbal form, required.
• Ability to independently research, understand and interpret complex healthcare claims data, civil and criminal laws, and contract requirements required.
• Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required.
• Strong working knowledge of investigative techniques and procedures as they relate to health care fraud, waste and abuse is required.
• Ability to gain a thorough understanding of PacificSource compliance initiatives.
• Respond timely to regulatory inquiries.
• Maintain sufficient reference materials to adequately research compliance issues.
• Ability to organize large complex investigative audits that involve working with multi-functional teams under strict deadlines.
• Ability to communicate effectively with all levels of the organization, federal and state agencies, providers, and members, both verbally and in writing.
• Working knowledge of legal and medical terminology.
• Ability to read, interpret, and apply the complex language and ideas found in provider contracts, case law, criminal and civil statues.
• Ability to work under time pressures, and remain professional in emotionally charged situations.
• Computer proficiency in a Windows environment, including Microsoft Office Suite.

Nice To Haves

• Experience in navigating case management, claims and OSINT platforms preferred.

Responsibilities

• Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims.
• Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.
• Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.
• Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.
• Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.
• Attend and participate in regional FWA Task Force and other state or federal meetings.
• Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies.
• Ensure regulatory reporting is developed, accurate, and submitted timely.
• Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.
• Develop and conduct internal FWA related training.
• Collaborate with government agencies during audits, investigations and Requests for Information (RFI).
• Present and discuss case findings and recommendations in case review meetings with department and company management.
• Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.
• Coordinate and manage the production of investigative materials in support of, settlement negotiations.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Benefits

• Our Values We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business: We are committed to doing the right thing. We are one team working toward a common goal. We are each responsible for customer service. We practice open communication at all levels of the company to foster individual, team and company growth. We actively participate in efforts to improve our many communities-internally and externally. We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community. We encourage creativity, innovation, and the pursuit of excellence.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior