Special Investigations Unit (SIU) Investigator II or III DOE

Cambia Health Solutions • Salt Lake, UT

3d • Hybrid

About The Position

This is a hybrid role for a Special Investigations Unit (SIU) Investigator II or III, requiring 3 days per week in the office at various locations including Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, and Lewiston. Candidates must reside within commuting distance of a listed office or be willing to relocate. The role involves conducting investigations into allegations of fraud and abuse within the healthcare system. Responsibilities include reviewing data, intelligence, and open-source information, performing audits, supporting recovery of inappropriate claims, and documenting findings. The investigator will also conduct interviews, identify evidence for referrals to agencies like CMS and HHS-OIG, and serve as a liaison between the SIU and other company departments. A key aspect of the role is proactively detecting and preventing fraudulent claims and educating employees, subscribers, and providers on fraud prevention. The position aims to ensure healthcare dollars are spent appropriately and to make the healthcare system work better for everyone.

Requirements

• 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.
• Proficient with Microsoft Office software programs.
• 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.
• Ability to work flexible schedules to accommodate investigation needs.
• Wired internet connection that is not satellite or cellular with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.
• Access to a personal mobile device to set up Multi-Factor Authentication (MFA).

Nice To Haves

• Certified Professional Coder (CPC) certification preferred.
• Experience with CMS and HHS-OIG/FBI or similar agencies preferred.
• Current RN or LPN licensure preferred.
• 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.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

Responsibilities

• Conducts investigations into allegations of fraud and abuse.
• Performs thorough review of available data, intelligence, evidence, and open source information.
• Performs onsite, prepayment, and desk audits.
• Provides investigative support in pursuing recovery of inappropriate and/or insupportable claims.
• Formulates audit and investigative reports and identifies and documents funds to be recovered and returned to the company.
• Conducts interviews and navigates contentious interactions calmly and professionally.
• Identifies and documents 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.
• Serves 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 pursues the detection and prevention of payment of fraudulent claims.
• Educates company employees, subscribers and providers regarding detection and prevention of health care fraud.
• Receives, analyzes and coordinates fraud and abuse complaints from internal and external sources.
• Conducts and coordinates moderately complex investigations with expertise across various case types.
• Participates in post-audit exit interviews where appropriate.
• Provides accurate accounting of recovered funds from audit activities, criminal or civil convictions and settlements.
• Maintains continuing education through anti-fraud and legal issue seminars.
• Reviews pertinent articles and regulatory requirements.
• Provides post-audit education to providers to correct discrepancies.
• Trains new Investigators and other Cambia employees in detection of abusive or fraudulent billing practices.
• Assists with maintenance of audit and investigation files.
• Assists with formulation of company policies addressing loss exposures and solutions.
• Maintains extensive contact with the provider community in both educational and potentially confrontational or adversarial investigative roles.
• Issues audit findings and prepayment claim determinations, including maintaining clear documentation of the basis of findings and determinations.
• Maintains the required professional judgment to support and deliver findings and determinations independently.
• Represents company at external and internal meetings dealing with fraud and abuse issues and litigation proceedings.
• Testifies in court as required.
• Develops professional working relationships with various associations and agencies for detection of local and national fraud and abuse schemes.
• Conducts witness and target interviews.
• Identifies and analyzes evidence.
• Examines records to verify document authenticity.
• Prepares and evaluates investigation reports.
• Provides information for affidavit preparation.
• Maintains communications with law enforcement and regulatory agencies to present case findings for further investigation, prosecution or administrative remedies.

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

What This Job Offers

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