Providence Senior Investigator, Special Investigation Unit *Remote* in Washington

[ad_1] Description Providence Health Plan caregivers are not simply valued – they’re invaluable. Join our team and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them. Providence Health Plan is calling a Senior Investigator, Special Investigation Unit who will: • Support 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 • Use professional communication skills to represent the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc. • Apply project management methodologies, specifically Agile / SCRUM We welcome 100% remote work for residents who reside in one of the following States: • Washington • Oregon • 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: • Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software • Basic understanding of statistics and data analytics • Advanced understanding of MS Excel and PowerPoint • Familiarity with Agile / Scrum and / or PMP Methodologies • Experience planning and conducting interviews specific to audits and / or investigations • Clinical background • 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) Why Join Providence? Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities. About Providence At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable. The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Check out our benefits page for more information about our Benefits and Rewards. About the Team Providence Shared Services is a service line within Providence that provides a variety of functional and system support services for our family of organizations across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. We are focused on supporting our Mission by delivering a robust foundation of services and sharing of specialized expertise. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment. We are committed to cultural diversity and equal employment for all individuals. It is our policy to recruit, hire, promote, compensate, transfer, train, retain, terminate, and make all other employment-related decisions without regard to race, color, religious creed (including religious dress and grooming practices), national origin (including certain language use restrictions), ancestry, disability (mental and physical including HIV and AIDS), medical condition (including cancer and genetic characteristics), genetic information, marital status, age, sex (which includes pregnancy, childbirth, breastfeeding and related medical conditions), gender, gender identity, gender expression, sexual orientation, genetic information, and military and veteran status or any other applicable legally protected status. We will also provide reasonable accommodation to known physical or mental limitations of an otherwise qualified caregiver or applicant for employment, unless the accommodation would impose undue hardship on the operation of our business. We are a community where all people, regardless of differences, are welcome, secure, and valued. We value respect, appreciation, collaboration, diversity, and a shared commitment to serving our communities. We expect that all workforce members in our community will act in ways which reflect a commitment to and accountability for, racial and social justice and equality in the workplace. As such, we will maintain a workplace free of discrimination and harassment based on any applicable legally protected status. We also expect that all workforce members will maintain a positive workplace free from any unacceptable conduct which creates an intimidating, hostile, or offensive work environment. Requsition ID: 246884 Company: Providence Jobs Job Category: Internal Audit Job Function: Finance Job Schedule: Full time Job Shift: Day Career Track: Business Professional Department: 5018 COMPLI PAYMENT INTEGRITY OR REGION Address: OR Beaverton 3601 SW Murray Blvd Work Location: Murray Business Ctr Beaverton-Beaverton Pay Range: $30.48 – $49.21 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities. Check out our benefits page for more information about our Benefits and Rewards. [ad_2] Apply tot his job Apply To this Job