Investigations Unit Investigator, Senior

Investigations Unit Investigator, Senior

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This position is responsible for administering the fraud, waste, and abuse (FWA) duties at an advanced level for CareOregon and its affiliated lines of business. Core work includes ensuring effective measures are in place and operating effectively to prevent, detect, and correct any instances of fraud, waste, and abuse. This includes performing advanced level of fraud investigations and providing regular FWA reporting to regulatory agencies. Additionally, this position helps ensure that appropriate procedures are in place and followed consistently to safeguard its assets, verify the accuracy and reliability of data, and promote efficient and effective operations.

Estimated Hiring Range:

$90,225.00 - $110,275.00

Bonus Target:

Bonus - SIP Target, 5% Annual

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

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Essential Responsibilities

• Contribute to the development and operation of an effective FWA program in accordance with CMS requirements and the Federal Sentencing Guidelines with guidance from department leadership.
• Perform routine and advanced FWA investigations, utilizing advanced investigative skills and diplomacy.
• Prepare reports of audit findings; provide recommendations regarding improvements or corrective actions where a deficiency may exist.
• Prepare routine and ad hoc reports for internal and external leaders, committees, and governing body, including collecting, analyzing, and displaying data.
• Prepare, proofread, and distribute correspondence, forms, and other information of a specialized and confidential nature.
• Develop and maintain an organized, methodical documentation system for communicating, implementing, and administering new and existing FWA regulatory requirements.
• Educate and coach leaders and staff regarding FWA requirements, including complex issues.
• Develop and/or utilize FWA dashboards and corresponding summaries used to identify and monitor current compliance and trending of all FWA matters including case details and metrics.
• Help identify potential areas of FWA vulnerability and risk; assist department leadership in developing and implementing corrective action plans for resolution of problematic issues and provide general guidance on how to avoid or deal with similar situations in the future.
• Participate in completing required Medicare and Medicaid filings and/or responses for FWA.

Experience and/or Education

Required

• Minimum 5 years’ experience in compliance and/or audit, including minimum 1 year experience focused on fraud, waste, and abuse
• CPC (Certified Professional Coder) or RHIT (Registered Health Information Technician) or CFE (Certified Fraud Examiner

Preferred

• Fraud, waste and abuse experience in Medicaid or Medicare

Knowledge, Skills and Abilities Required

Knowledge

• Advanced understanding of healthcare fraud, waste and abuse
• Strong knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid Programs
• Advanced knowledge of investigative techniques, including interviews, data analytics, evidence gathering, case documentation
• Solid understanding of information and reporting systems

Skills and Abilities

• Strong communication skills, including written, verbal and listening skills
• Advanced research, investigative and problem-solving skills
• Growing ability to build conceptual models and communicate complex ideas effectively
• Ability to facilitate learning opportunities in a variety of informal and formal settings
• Ability to make presentations to small and large groups
• Ability to think logically and creatively without undue influence from personal biases
• Ability to plan, organize, and monitor work projects
• 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 perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 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.