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PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Senior Investigator manages work related to fraud, waste and abuse audits and investigations across several independent and specialized teams. Functions include, conducting in depth investigations making decisions and recommendations on case direction, scope and timing; collaborating with managers and staff in Claims, Provider Network, Appeals and Grievances, Finance, Utilization Management and Analytics throughout the audit lifecycle; ensuring audit compliance with state and federal laws and regulations, contract requirements and company policies and procedures as they pertain to fraud, waste and abuse.

Essential Responsibilities:

• Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims,
• Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.
• Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.
• Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.
• Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.
• Attend and participate in regional FWA Task Force and other state or federal meetings.
• Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies.
• Ensure regulatory reporting is developed, accurate, and submitted timely.
• Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.
• Develop and conduct internal FWA related training.
• Collaborate with government agencies during audits, investigations and Requests for Information (RFI).
• Present and discuss case findings and recommendations in case review meetings with department and company management.
• Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.
• Coordinate and manage the production of investigative materials in support of, settlement negotiations.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 4 years of experience conducting complex healthcare fraud investigations required. Significant experience in facilitating audit activities across specialized teams required. Ability to effectively and professionally communicate with internal and external stakeholders, in both written and verbal form, required. Ability to independently research, understand and interpret complex healthcare claims data, civil and criminal laws, and contract requirements required. Experience in navigating case management, claims and OSINT platforms preferred.

Education, Certificates, Licenses: Bachelor’s degree in business administration, criminal justice, or related field or a combination of equivalent education and experience is required. Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required.

Knowledge: Strong working knowledge of investigative techniques and procedures as they relate to health care fraud, waste and abuse is required. Ability to gain a thorough understanding of PacificSource compliance initiatives.