Investigator - Special Investigations Unit (SIU) Apply
Hybrid from WA, OR, UT, or ID
Primary Job Purpose
The Investigator Special Investigations Unit (SIU) conducts proactive and reactive investigations of alleged Fraud and Abuse. Pursues recovery of overpayments related to Fraud or Abuse across all Cambia lines of business. Conducts and documents investigative activities in support of recoupment efforts, and/or refers cases to Law Enforcement, the Centers for Medicare & Medicaid (CMS), HHS-OIG, or regulatory agencies for administrative or criminal action.
General Functions and Outcomes
Benefits
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.
Primary Job Purpose
The Investigator Special Investigations Unit (SIU) conducts proactive and reactive investigations of alleged Fraud and Abuse. Pursues recovery of overpayments related to Fraud or Abuse across all Cambia lines of business. Conducts and documents investigative activities in support of recoupment efforts, and/or refers cases to Law Enforcement, the Centers for Medicare & Medicaid (CMS), HHS-OIG, or regulatory agencies for administrative or criminal action.
General Functions and Outcomes
- Receives, analyzes, and coordinates complaints of fraud and abuse from internal and external sources. External sources include members, providers, state and federal regulatory agencies and law enforcement agencies. Internal sources include Customer Service, Claims, and other Cambia departments.
- Conducts and coordinates investigations. Participates in interviews with providers, members, or other subjects and witnesses where appropriate.
- Supplies accurate accounting of funds recovered from auditing activities, criminal or civil convictions, and settlements. Successfully negotiates settlement agreements and completes recovery of funds including any necessary collection activities.
- Maintains a program for continuing education through attendance at Anti-Fraud and legal issue seminars and other programs affecting the third-party payer system. Reviews pertinent articles, regulatory requirements and other documents affecting policies and rights of recovery.
- Provides education to providers to ensure compliance. .
- Aids with the maintenance of investigative files.
- Maintains some contact with the provider community, both in an educational role as well as possible confrontational or adversarial role in the investigation
- Represents company at external and internal meetings and/or litigation proceedings and testifies in court proceedings as needed.
- Develops and maintains a professional working relationship for the detection of local and national fraud and abuse schemes with various associations and agencies.
- Support multi-disciplinary or multi-agency investigations by: 1) Conducting interviews of witnesses, informants, subject area experts and/ or targets of investigations; 2) Identifying, collecting, preserving, analyzing and summarizing evidence, examining records, to verify the authenticity of documents. May provide information to support the preparation of affidavits or supervising the preparation of affidavits as needed; 3) Preparing, and evaluating investigation reports, and promotes effective and efficient investigations; 4) Initiating and maintaining communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting case findings for tier consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
- Bachelors degree, Program Certification (i.e., Fraud Examiner or Criminal Justice), or successful completion of law enforcement academy, with one year of job-related experience or equivalent combination of education and work-related experience.
- Experience with CMS and HHS-OIG/FBI or similar agencies preferred.
- Knowledge of medical procedures, medical terminology, and/or investigations
- Experience with Cambia or other similar types of third-party payer or with independenthealth services contractor is desired.
- Proficient with Microsoft Office software programs
- Excellent written, oral, and interpersonal skills
- Investigative skills, experience, and/or exposure to the criminal justice system are desirable.
- Ability to manage confidential information and multiple tasks.
- Previous experience in report preparation and project management
- Analytical ability to identify problems, develop solutions and implement a chosen course of action.
- Demonstrated ability to coordinate activities with varying levels of management, staff, external agencies and/or medical professionals through strong verbal and written communications.
- Demonstrated maturity and tact, with the ability to be diplomatic and persuasive in situations requiring those qualities.
- Demonstrated ability to work independently, yet function within the corporate structure.
- Ability to learn appropriate state codes and regulations about the health care and insurance industries and learn legal procedures and medical terminology.
- Must have personal, reliable transportation, a valid drivers license and proof of automobile insurance to meet on-site audit and investigative requirements.
- Ability to tolerate stressful and/or confrontational situations and keep composure.
- Ability to work flexible work schedules to accommodate deadlines.
- Travel to audit sites and between Plan locations occasionally required.
- Some stressful and/or confrontational situations.
- Possible court appearances for testifying.
Benefits
Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:
- medical, dental, and vision coverage for employees and their eligible family members
- annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)
- paid time off varying by role and tenure in addition to 10 company holidays
- up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)
- up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)
- one-time furniture and equipment allowance for employees working from home
- up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to the health of our communities and employees during the COVID-19 pandemic. Please review the policy on our Careers site.
