Investigator, Special Investigation Unit *Remote*
About the position
The Investigator for the Special Investigation Unit (SIU) at Providence Health Plan is responsible for conducting compliance-related audits and investigations to identify and address fraudulent and abusive billing and coding practices. This role involves collaboration with subject matter experts, data analysis for fraud risk identification, and providing education on compliance and fraud prevention. The position requires managing multiple cases and audits, coordinating recovery of overpayments, and presenting findings to various stakeholders.
Responsibilities
Support timely completion of compliance-related audits and investigations of the Special Investigations Unit (SIU) at the Health Plan
,
Collaborate with subject matter experts to identify, investigate, and correct fraudulent and/or abusive billing and coding practices
,
Leverage credible sources of information from Internet research in case preparation
,
Proactively learn and apply data analysis related to fraud risk identification and prevention
,
Manage a workload with multiple cases and audits simultaneously
,
Assist Senior Investigator or SIU Director in developing, implementing, and performing compliance-related auditing and monitoring activities
,
Coordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices
,
Keep organized audit work papers that enable collaboration with external teams in the audit and recovery process
,
Coordinate with parties with compliance accountabilities to facilitate corrective action completion and behavior change
,
Provide education related to coding, medical record documentation requirements, healthcare compliance, and fraud, waste, and abuse to Health Plan staff, vendors, and contracted providers/facilities
,
Support team in peer review and delivery of quality work product
,
Present on fraud risk in a professional manner, in written and oral reports, tailored to providers, executives, members, and regulators
,
Submit timely and professional reports of case findings to regulators, law enforcement, and internal business partners
,
Provide training on fraud prevention to executives, caregivers, business partners, and members
,
Support timely processing of risk report intake triage and prepay audit claims
Requirements
Bachelor's Degree or a combination of equivalent education and experience
,
5+ years coding experience at a healthcare provider, facility, or health insurance company
,
2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility, or other relevant healthcare environment
,
Project management experience, education program development experience, and group presentation experience
,
Experience in use of data mining software/tools
Nice-to-haves
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 equivalent
,
Certification in Project Management or Agile (PMP, CSM, CSPO)
,
Basic understanding of statistics and data analytics
,
Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software
,
Advanced understanding of MS Excel and PowerPoint
,
Professional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc.
Benefits
401(k) Savings Plan with employer matching
,
Health care benefits (medical, dental, vision)
,
Life insurance
,
Disability insurance
,
Paid parental leave
,
Vacation and holiday time off
,
Voluntary benefits
,
Well-being resources
Apply Now
The Investigator for the Special Investigation Unit (SIU) at Providence Health Plan is responsible for conducting compliance-related audits and investigations to identify and address fraudulent and abusive billing and coding practices. This role involves collaboration with subject matter experts, data analysis for fraud risk identification, and providing education on compliance and fraud prevention. The position requires managing multiple cases and audits, coordinating recovery of overpayments, and presenting findings to various stakeholders.
Responsibilities
Support timely completion of compliance-related audits and investigations of the Special Investigations Unit (SIU) at the Health Plan
,
Collaborate with subject matter experts to identify, investigate, and correct fraudulent and/or abusive billing and coding practices
,
Leverage credible sources of information from Internet research in case preparation
,
Proactively learn and apply data analysis related to fraud risk identification and prevention
,
Manage a workload with multiple cases and audits simultaneously
,
Assist Senior Investigator or SIU Director in developing, implementing, and performing compliance-related auditing and monitoring activities
,
Coordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices
,
Keep organized audit work papers that enable collaboration with external teams in the audit and recovery process
,
Coordinate with parties with compliance accountabilities to facilitate corrective action completion and behavior change
,
Provide education related to coding, medical record documentation requirements, healthcare compliance, and fraud, waste, and abuse to Health Plan staff, vendors, and contracted providers/facilities
,
Support team in peer review and delivery of quality work product
,
Present on fraud risk in a professional manner, in written and oral reports, tailored to providers, executives, members, and regulators
,
Submit timely and professional reports of case findings to regulators, law enforcement, and internal business partners
,
Provide training on fraud prevention to executives, caregivers, business partners, and members
,
Support timely processing of risk report intake triage and prepay audit claims
Requirements
Bachelor's Degree or a combination of equivalent education and experience
,
5+ years coding experience at a healthcare provider, facility, or health insurance company
,
2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility, or other relevant healthcare environment
,
Project management experience, education program development experience, and group presentation experience
,
Experience in use of data mining software/tools
Nice-to-haves
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 equivalent
,
Certification in Project Management or Agile (PMP, CSM, CSPO)
,
Basic understanding of statistics and data analytics
,
Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software
,
Advanced understanding of MS Excel and PowerPoint
,
Professional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc.
Benefits
401(k) Savings Plan with employer matching
,
Health care benefits (medical, dental, vision)
,
Life insurance
,
Disability insurance
,
Paid parental leave
,
Vacation and holiday time off
,
Voluntary benefits
,
Well-being resources
Apply Now