Special Investigations Unit (SIU) Investigator II or III DOE

Cambia Health Solutions • Medford, OR

5d • $59,000 - $97,000 • Hybrid

About The Position

Every day, Cambia’s dedicated team of SIU Investigators are living our mission to make health care easier and lives better. As a member of the Special Investigations Unit, our SIU Investigator conducts investigations into allegations of fraud and abuse. Responsibilities include performing 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 – all in service of creating a person-focused health care experience.

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.
• 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
• Proficient with Microsoft Office software programs and 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, with ability to work flexible schedules to accommodate investigation needs

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
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Responsibilities

• Receives, analyzes and coordinates fraud and abuse complaints from internal sources (customer services, claims processing, underwriting, professional affairs) and external sources (members, providers, state and federal regulatory agencies, law enforcement), then conducts and coordinates moderately complex investigations with expertise across various case types, participating in post-audit exit interviews where appropriate
• Provides accurate accounting of recovered funds from audit activities, criminal or civil convictions and settlements, demonstrating continuing success in settlement, recovery and collection activities related to fraudulent activity
• Maintains continuing education through anti-fraud and legal issue seminars, holds at least one professional credential (CPC, CPC-H or CPC-P), reviews pertinent articles and regulatory requirements, and provides post-audit education to providers to correct discrepancies, and trains new Investigators and other Cambia employees in detection of abusive or fraudulent billing practices
• Assists with maintenance of audit and investigation files, formulation of company policies addressing loss exposures and solutions, and 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, and maintaining the required professional judgment to support and deliver them independently
• Represents company at external and internal meetings dealing with fraud and abuse issues and litigation proceedings, testifies in court as required, and develops professional working relationships with various associations and agencies for detection of local and national fraud and abuse schemes
• Conducting witness and target interviews, identifying and analyzing evidence, examining records to verify document authenticity, preparing and evaluating investigation reports, providing information for affidavit preparation, and maintaining 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