Senior Investigator

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

Position Overview: The Senior Investigator manages work related to fraud, waste and abuse audits and investigations across several independent and specialized teams. Functions include, conducting in depth investigations making decisions and recommendations on case direction, scope and timing; collaborating with managers and staff in Claims, Provider Network, Appeals and Grievances, Finance, Utilization Management and Analytics throughout the audit lifecycle; ensuring audit compliance with state and federal laws and regulations, contract requirements and company policies and procedures as they pertain to fraud, waste and abuse.

Essential Responsibilities:

• Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims,
• Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.
• Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.
• Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.
• Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.
• Attend and participate in regional FWA Task Force and other state or federal meetings.
• Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, cataloged, and disseminated to the appropriate agencies.
• Ensure regulatory reporting is developed, accurate, and submitted timely.
• Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.
• Develop and conduct internal FWA related training.
• Collaborate with government agencies during audits, investigations and Requests for Information (RFI).
• Present and discuss case findings and recommendations in case review meetings with department and company management.
• Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.
• Coordinate and manage the production of investigative materials in support of, settlement negotiations.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience: Minimum 4 years of experience conducting complex healthcare fraud investigations required. Significant experience in facilitating audit activities across specialized teams required. Ability to effectively and professionally communicate with internal and external stakeholders, in both written and verbal form, required. Ability to independently research, understand and interpret complex healthcare claims data, civil and criminal laws, and contract requirements required. Experience in navigating case management, claims and OSINT platforms preferred.

Education, Certificates, Licenses: Bachelor’s degree in business administration, criminal justice, or related field or a combination of equivalent education and experience is required. Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required.

Knowledge: Strong working knowledge of investigative techniques and procedures as they relate to health care fraud, waste and abuse is required. Ability to gain a thorough understanding of PacificSource compliance initiatives. Respond timely to regulatory inquiries. Maintain sufficient reference materials to adequately research compliance issues. Ability to organize large complex investigative audits that involve working with multi-functional teams under strict deadlines. Ability to communicate effectively with all levels of the organization, federal and state agencies, providers, and members, both verbally and in writing. Working knowledge of legal and medical terminology. Ability to read, interpret, and apply the complex language and ideas found in provider contracts, case law, criminal and civil statues. Ability to work under time pressures, and remain professional in emotionally charged situations. Computer proficiency in a Windows environment, including Microsoft Office Suite.

Competencies

• Building Trust
• Building a Successful Team
• Aligning Performance for Success
• Building Partnerships
• Customer Focus
• Continuous Improvement
• Decision Making
• Facilitating Change
• Leveraging Diversity
• Driving for Results

Environment : Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Our Values

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We encourage creativity, innovation, and the pursuit of excellence.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.