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Special Investigation Unit who will:

• Support the compliance related activities of the Special Investigations Unit (SIU) at the Health Plan
• Lead in developing, implementing and performing compliance related auditing and monitoring projects at the Health Plan, ensuring timely completion of case files, reports, law enforcement referrals, and provider educational letters
• Lead in risk sizing and prioritization, applying data-driven approaches such as outlier analysis and possibly network analysis
• Identify, investigate and correct fraudulent and/or abusive billing and coding practices.
• Coordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices; 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, fraud, waste and abuse to Health Plan staff, vendors and contracted providers/facilities
• Support team in peer review; mentors team on investigation techniques and audit/investigation workpaper disciplines; supports the team in delivery of quality work product, including integrating checks on their own work product
• Provide training on fraud prevention to executives, caregivers, business partners, and members
• Supports team in timely processing of risk report intake triage, timely processing of prepay audit claims, and other compliance requirements.

We welcome 100% remote work for residents who live in the States of Washington, Oregon and California.

Required qualifications for this position include:

• Bachelor's Degree -OR- a combination of equivalent education and experience
• 5+ years coding experience with a healthcare provider, facility or health insurance company
• 5+ years fraud and abuse audit experience in a Health Plan
• Project management experience, education program development experience and group presentation experience
• Experience in use of data mining software/tools

Preferred qualifications for this position include:

• Current certification as an Accredited Healthcare Fraud Investigator (AHFI)
• Certification as an Internal Auditor (CIA) or Healthcare Compliance certification (CHC or equivalent)
• Current certification as a Certified Coding Professional (CPC)
• 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.
• Clinical background

Job Type: Full-time

Pay: $60,922.69 - $79,390.77 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 10 hour shift
• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Military: 1 year (Required)
• Surveillance: 3 years (Required)
• coding: 5 years (Required)
• fraud and abuse audit: 5 years (Required)
• management: 2 years (Preferred)

License/Certification:

• Driver's License (Required)

Work Location: Remote