Full Time - Regular
Roseburg, OR, US
Requisition ID: 1651
Umpqua Health is a Coordinated Care Organization (CCO) in Roseburg, Oregon that serves over 30,000 OHP members within Douglas County, offering benefits, programs and outreach for those in need. Currently we are seeking a Compliance Investigator to join our team.
The Compliance Investigator is responsible for preventing, detecting, investigating, and resolving health care fraud, waste, and abuse. The Compliance Investigator will represent a high level of professionalism both internally and externally while working with the Compliance team to conduct investigations in accordance with company policies and procedures and in compliance with all applicable laws and regulations.
- Full Time position with the option of Remote work (Must live in OR or WA).
- Generous benefit package including; PTO, Health/Vision/Dental Insurance, 401k with a company match, gym membership reimbursement and more.
- $61,000-$82,000 Annual Salary DOE.
ESSENTIAL JOB RESPONSIBILITIES
- Work with the Chief Compliance Officer to facilitate the implementation the organization’s Compliance Program and Annual Work Plan.
- Assist in development, implementation and maintenance of internal audit policies and procedures in accordance with best practice.
- Initiate, analyze, develop, and successfully complete complex fraud investigations and support other team members as needed.
- Develop and maintain relationship with personnel at other insurance carriers, CCO and law enforcement agencies as needed.
- Develop and maintain relationships with personnel from other departments within the CCO and within partnering or other community organizations.
- Develop relationships with personnel from OHA and other professional entities as applicable to job duties and resolution.
- Be responsible for coordinating and overseeing efforts to recover erroneous payments made because of a claims processing error, misrepresentative billing, fraud, abuse, or any other criminal act.
- Stay up to date with contractual, state and federal regulations.
- Responsible in implementing the Annual FWA Prevention Plan
- Responsible for FWA reporting to regulatory agencies.
- Document all stages of each investigation using Umpqua Heath and department procedures, templates, and forms. Prepare detailed post-audit investigative reports.
Meet mandatory core and specialized training requirements as required.
- Handle highly confidential and sensitive information while ensuring compliance with privacy policies.
- Prioritize and practice excellent time management and organizational skills.
- Work flexible work schedules to accommodate investigations.
- Assist and participate in other compliance initiatives to support the broader Umpqua Health’s Compliance Program. Such activities include training development, auditing, policy creation.
- Identify problems, develop solutions, and implement a chosen course of action.
- Comply with organization’s internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
- Requires a high school diploma (bachelor’s degree preferred) or equivalent work experience, as well as thorough experience in health care, legal services or a least two (2) 5 years investigations experience.
- Requires either a CPC or equivalent medical coding certificate, Certified Fraud Examiner, Health Care Anti-Fraud Associate, Accredited Health Care Fraud Investigator, or Certified Professional Medical Auditor
- Must possess knowledge of health insurance reimbursement methodologies, including ICD-10 CM, CPT and HCPCS coding.
- Have knowledge about the provision of medical assistance under Title XIX of the Act and about the operations of health care Providers.
- Extensive knowledge of investigations typically obtained through advanced education and/or previous job experience.
- Excellent written, oral, presentation, interpersonal, and negotiation skills.
- Able to read and understand medical documentation.
- Demonstrated knowledge and experience of Medicaid, Medicare, and other government programs.
- Demonstrates knowledge of provider investigations related to pharmacy
- Demonstrates experience working with provider and State Offices
For more information or to apply visit our website at www.umpquahealthcareers.com