Investigator, Special Investigation Unit

About the position

The Investigator for the Special Investigation Unit (SIU) at Providence Health Plan plays a crucial role in ensuring compliance and integrity within healthcare billing practices. This position involves conducting audits and investigations related to fraudulent and abusive billing, collaborating with experts, and providing education on compliance and coding requirements. The role requires strong analytical skills and the ability to manage multiple cases simultaneously, contributing to the overall mission of patient-focused care.

Responsibilities
? Support timely completion of compliance related audits and investigations of the Special Investigations Unit (SIU) at the Health Plan.
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? Collaborate with subject matter experts to identify, investigate and correct fraudulent and/or abusive billing and coding practices.
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? Leverage credible sources of information from Internet research in case preparation.
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? Proactively learn and apply data analysis related to fraud risk identification and prevention.
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? Manage a workload with multiple cases and audits simultaneously.
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? Assist Senior Investigator or SIU Director in developing, implementing and performing compliance related auditing and monitoring activities.
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? Coordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices.
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? 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.
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? Support team in peer review and delivery of quality work product, including integrating checks on their own work product.
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? Submit timely and professional reports of case findings to regulators, law enforcement, and internal business partners.

Requirements
? Bachelor's Degree -OR- a combination of equivalent education and experience.
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? 5+ years coding experience at a healthcare provider, facility or health insurance company.
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? 2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility or other relevant healthcare environment.
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? Project management experience, education program development experience and group presentation experience.
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? 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).
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? Current certification as Certified Coding Professional (CPC).
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? 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.
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? Certification in Project Management or Agile (PMP, CSM, CSPO).
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? Basic understanding of statistics and data analytics.
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? Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software.
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? Advanced understanding of MS Excel and PowerPoint.
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? Professional communication skills, representing the SIU in verbal and written communications.

Benefits
? 401(k) matching
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? Dental insurance
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? Disability insurance
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? Health insurance
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? Life insurance
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? Opportunities for advancement
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? Paid holidays

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