Special Investigations Unit Investigator

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

Job Title	Special Investigations Unit Investigator
Department	Health Share of Oregon
Exemption Status	Exempt
Requisition #	24845
Direct Reports	N/A
Manager Title	Director of Compliance and Quality Oversight
Pay & Benefits	Estimated hiring range $73,035 - $89,265 / year, 5% bonus target, full benefits. www.careoregon.org/about-us/careers/benefits
Posting Notes	This is a fully remote role, but you must reside in 1 of the listed 9 states (Must be able to work (9-3P.M. PST - Flexible if in Central Time).

Job Summary

The Special Investigations Unit (SIU) Investigator position is responsible for administering the fraud, waste, and abuse (FWA) duties for Health Share of Oregon. This work includes delegation oversight of subcontracted entities corporate risk assessment and compliance education and technical assistance. 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 fraud investigations and providing regular FWA reporting. 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. This position develops, designs, implements, and oversees policies and processes to assess compliance with delegated FWA functions and assurance of provision of quality services to Health Share members. This position is responsible for the collaboration between Health Share and subcontracted entity staff to ensure that all delegated functions and quality oversight activities are meeting federal, state and Health Share contracted and regulatory requirements.

Essential Responsibilities

• Assist in the development and operation of an effective FWA program in accordance with CMS requirements, OHA/OHP requirements, and the Federal Sentencing Guidelines with guidance from department leadership.
• Assist in the development and implementation of policies and procedures that meet OHA contractual requirements and Federal Sentencing Guidelines.
• Provide oversight monitoring and audits of subcontracted entities' FWA program activities and recommend corrective action per policy.
• Perform routine FWA investigations, audits, and corrective actions as assigned, including maintaining documents and providing routine updates; coordinate with subcontracted entity staff as indicated.
• Prepare reports of audit findings; provide recommendations regarding improvements or corrective actions where a deficiency may exist.
• Prepare, proofread, and distribute correspondence, forms, and other information of a specialized and confidential nature.
• Respond to routine and ad hoc requests from external regulatory agencies as assigned, such as annual reviews, quarterly reports, and ad hoc requests.
• Prepare routine and ad hoc reports for internal and external leaders, committees, and governing body, including collecting, analyzing, and displaying data.
• Assist in developing and maintaining an organized, methodical documentation system for communicating, implementing, and administering new and existing FWA regulatory requirements.
• Review and recommend policy and procedure revisions that support the FWA/SIU program.
• Attend internal and external FWA and compliance-related meetings as assigned.
• Assist in providing effective FWA training and education to staff, both internal and external.
• Act as a Subject Matter Expert (SME) and provide education and training to Health Share and subcontracted entity staff on FWA requirements, risks, and appropriate mitigation.
• Participate in FWA program-related risk assessment and mitigation processes.
• Ensure alignment of project outcomes with the CCO's commitment to racial equity and the goals of the CCO's Community Health Improvement Plan.
• Work collaboratively to analyze project needs, identify solutions, and inform leadership and health system partners of strategic opportunities.
• Facilitate consensus and collaboration among diverse stakeholders and partners using influencing skills when required and always with diplomacy and discretion.

Organizational Responsibilities

• Perform work in alignment with the organization's mission, vision and values.
• Support the organization's commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support the organization's strategic goals.
• Adhere to the organization's policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Knowledge, Skills and Abilities Required

Knowledge:

• Strong knowledge of federal, state, and national health care compliance regulations related to Medicaid (Title XIX of the Social Security Act)
• Advanced understanding of healthcare fraud, waste, and abuse
• Knowledge of investigative techniques, including interviews, data analytics, evidence gathering, case documentation
• Understanding of program integrity/FWA reporting systems

Core Skills and Abilities:

• Competency with computer software programs (i.e., MS Outlook, Word, Excel, and PowerPoint)
• Ability to research, understand, interpret, and communicate federal and state requirements, including the Code of Federal Regulations, Oregon Revised Statutes and Administrative Rules, HIPAA, Fraud, Waste, and Abuse laws, False Claims Act, Anti-Kickback laws, etc.
• Understanding of the audit process, including the development of audit plans (objectives, methodology, sampling, testing) and preparation of work papers and documentary evidence in accordance with professional auditing standards
• Ability to set goals independently and prioritize work to balance competing deadlines in a professional manner, while managing multiple tasks
• Excellent engagement and partnership skills, including written and verbal communication with a broad array of stakeholders, including public presentations of data and complex processes as needed
• Ability to work in an environment with diverse individuals and groups
• Ability to work well under pressure in a complex and rapidly changing environment
• Well-developed organizational, problem-solving, and time-management skills
• Ability to gather, compile and organize data
• Ability to build and maintain effective relationships and collaboration
• Ability to effectively review and organize systems and workflows
• Ability to manage project scope and timelines effectively
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to assess a situation and seek or determine appropriate resolution

Physical Skills and Abilities:

• 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

Cognitive Skills and Abilities:

• Adept at utilizing various approaches to achieve favorable outcomes, manage change, and influence others
• Ability to work effectively with diverse individuals and groups
• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to focus on and comprehend information and learn new skills and abilities
• Ability to accept managerial direction and feedback and tolerate and manage stress

Education and/or Experience

Required:

• Minimum 2 years' experience in healthcare FWA, compliance, and/or auditing in an operational setting within a highly regulated industry.
• FWA investigation experience in healthcare or with health insurance organization.
• CFE (Certified Fraud Examiner) or RHIT (Registered Health Information Technician) or CPC (Certified Professional Coder)

Working Conditions

Primary Work Environment:

Indoor/Office Member Facing Patient Facing Facilities/Security

Other Work Environment(s):

Indoor/Office Member Facing Patient Facing Facilities/Security Outdoor Exposure

Hazards: General office hazards, which most commonly include potential physical and ergonomic hazards, such as falls, cuts, repetitive strains, accidents, etc.

Equipment: General office equipment

Travel: This position 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

#MULTI

Health Share is an equal opportunity employer and employs personnel without regard to age, citizenship, color, creed, physical or mental disability, economic status, education, ethnicity, family responsibilities, gender identity and expression, genetic information, health status including HIV status, height, housing status, marital status, matriculation, national origin, physical appearance, race, religion, political affiliation, pregnancy, sex, sexual orientation, union membership, veteran status or other unlawful factors, with respect to recruiting, hiring, job assignment, promotion, discipline, discharge, compensation, training and other terms, conditions and privileges of employment and contracting.

Health Share is committed to creating a diverse staff made of people who are dedicated, optimistic and committed to health equity from all segments of the greater Portland Region, and we encourage people of color, people with disabilities, LGBTQ+ people, women and nonbinary people, and Veterans to apply for consideration.

Visa sponsorship is not available at this time.