SUMMARY
This position is responsible for coordinating the day-to-day responsibilities of the Fraud, Waste, and Abuse program in compliance with the rules and regulations of the Oregon Health Authority, State of Oregon, and the Federal Government Healthcare Programs. This position works with the Compliance Officer on audits, policies and procedures, training, and regulatory reporting by performing the following duties.
- Maintains a program that identifies and prevents Fraud, Waste, and Abuse.
- Writes and maintains internal documents, processes, and policies and procedures related to the Fraud, Waste, and Abuse Program.
- Plans and conducts billing and coding audits, policy and procedure audits, training audits, and investigations related to the Fraud, Waste, and Abuse Program.
- Completes required regulatory reporting timely and accurately.
- Develops audit work plans and performs auditing and monitoring consistent with the plan.
- Reviews materials submitted including policies, sample files, program documentation and other materials relevant to the audit protocol.
- Writes reports summarizing finding of audits.
- Monitors corrective action plans submitted in response to audit findings.
- Reviews and analyzes claims, prior authorizations, and other system information necessary to provide services to members for Fraud, Waste, and Abuse.
- Coordinates with other departments and agencies to facilitate detection, prevention, and referrals of potential Fraud, Waste, and Abuse.
- Initiates and maintains communications with appropriate regulatory agencies including presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
- Testifies at various legal proceedings as necessary.
- Facilitates the recovery of funds lost as a result of fraud, waste, and abuse matters.
- Creates and delivers training to staff designed to promote deterrence and detection of fraud, waste, and abuse.
- Participates in the annual risk assessment to identify and evaluate delegation risk as part of the Enterprise Risk Management program.
- Conducts Fraud, Waste, and Abuse investigations and documents case activity appropriately, working with subcontractors as needed.
- Participates in preparation and response to regulatory audits.
- Maintains a working knowledge of applicable Federal and State regulations, including Medicaid requirements under Oregon law and Federal requirements under Title XIX of the Social Security Act and supporting regulations.
- Stays current with regulatory requirement through review of periodicals, compliance association newsletters and review of state and federal regulatory agency web sites, publications and contracts.
- Maintains confidentiality and complies with HIPAA rules and regulations.
- Maintains punctual, regular and predictable attendance.
- Works collaboratively in a team environment with a spirit of cooperation.
- Displays excellent communication skills including presentation, persuasion, and negotiation skills required in working with members and coworkers, including the ability to communicate effectively and remain calm and courteous under pressure.
- Respectfully takes direction from manager.
EDUCATION and/or EXPERIENCE
Bachelor's Degree from four-year college or university and two to four years related experience and/or training; or equivalent combination of education and experience. Related experience required as an investigator, paralegal, professional coder, or auditor in the health care industry.
COMPUTER SKILLS
Job requires specialized computer skills. Must be adept at using various applications including database, spreadsheet, report writing, project management, graphics, word processing, presentation creation/editing, communicate by e-mail and use scheduling software.
CERTIFICATES, LICENSES, REGISTRATIONS
Certified Fraud Examiner (DFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Internal Auditor (CIA) or Certified Professional Coder (CPC) is preferred.
We provide a competitive salary and excellent benefits, including vacation, medical, dental and vision insurance, and 401(k) pension plan. To apply for this position, please submit a cover letter and resume. We are an Equal Opportunity Employer.