Job Information
Providence St. Joseph Health Senior Investigator, Special Investigation Unit *Remote* in Renton, Washington
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 "Kno