Investigator, Special Investigation Unit *Remote*
Providence Health & Services - Washington, DC
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DescriptionThe information below covers the role requirements, expected candidate experience, and accompanying qualifications.Providence Health Plan caregivers are not simply valued - they're invaluable. Join our team and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.Providence Health Plan is calling an Investigator, Special Investigation Unit who will:Support timely completion of compliance related audits and investigations of the Special Investigations Unit (SIU) at the Health PlanCollaborate with and learn from subject matter experts to identify, investigate and correct fraudulent and/or abusive billing and coding practices, which may advance in complexity with experienceLeverage credible sources of information from Internet research in case preparationProactively learns and applies data analysis related to fraud risk identification and preventionAble to manage a workload with multiple cases and audits simultaneouslyMay assist Senior Investigator or SIU Director in developing, implementing and performing compliance related auditing and monitoring activities at the Health PlanCoordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices; keeps organized audit work papers that enables collaboration with external teams in the audit and recovery processCoordinate with parties with compliance accountabilities to facilitate corrective action completion and behavior changeProvide education related to coding, medical record documentation requirements, healthcare compliance and fraud, waste and abuse to Health Plan staff, vendors and contracted providers/facilitiesSupport team in peer review and delivery of quality work product, including integrating checks on their own work productPresents on fraud risk in a professional manner, in written and oral reports, tailored to providers, executives, members, and regulatorsSubmit timely and professional reports of case findings to regulators, law enforcement, and internal business partnersProvide training on fraud prevention to executives, caregivers, business partners, and membersSupports timely processing of risk report intake triage, timely processing of prepay audit claims, and other compliance requirementsPlease note the following important detail regarding this role:This position is affiliated with Providence Health Plan and will be tied to a location and compensation range in Beaverton, OregonProvidence Health Plan welcomes 100% remote work for residents of the following States:WashingtonOregonCaliforniaRequired qualifications for this position include:Bachelor's Degree -OR- a combination of equivalent education and experience5+ years coding experience at a healthcare provider, facility or health insurance company2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility or other relevant healthcare environmentProject management experience, education program development experience and group presentation experienceExperience in use of data mining software/toolsPreferred qualifications for this position include:Clinical background such as Registered Nurse (RN), Doctorate of Medicine (MD), or Doctor of Chiropractic (DC)Current certification as Certified Coding Professional (CPC)Current certification in health care fraud investigation, such as Accredited Healthcare Fraud Investigator (AHFI), Certification as an Internal Auditor (CIA), Healthcare Compliance certification (CHC), or equivalentCertification in Project Management or Agile (PMP, CSM, CSPO)Basic understanding of statistics and data analyticsBasic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics softwareAdvanced understanding of MS Excel and PowerPointProfessional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc.Why Join Providence Health Plan?Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.About ProvidenceAt Providence, our strength lies in Our Promise of "Know me, care for me, ease my way." Working at our family of organizations means that regardless of your role, we'll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.Requsition ID: 317087Company: Providence JobsJob Category: Internal AuditJob Function: FinanceJob Schedule: Full timeJob Shift: DayCareer Track: Business ProfessionalDepartment: 5018 COMPLI PAYMENT INTEGRITY OR REGIONAddress: OR Beaverton 3601 SW Murray BlvdWork Location: Murray Building - Home Service West PortlandWorkplace Type: RemotePay Range: $27.86 - $43.46The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.#J-18808-LjbffrRemote working/work at home options are available for this role.
Created: 2024-10-16