Healthcare Fraud Investigator II: Hybrid Role with Impact

Hybrid role (3 days/week in office) at our Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, Lewiston offices.

Candidates must reside within commutable distance of that location or be willing to relocate

Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Every day, Cambia’s dedicated team of SIU Investigators are living our mission to make health care easier and lives better. As a member of the Special Investigations Unit, our SIU Investigator conducts investigations into allegations of fraud and abuse. Responsibilities include performing thorough review of available data, intelligence, evidence, and open source information. Performs onsite, prepayment, and desk audits. Provides investigative support in pursuing recovery of inappropriate and/or insupportable claims.

Formulates audit and investigative reports and identifies and documents funds to be recovered and returned to the company. Conducts interviews and navigates contentious interactions calmly and professionally. Identifies and documents evidence and intelligence to support and perform case referrals to the Centers for Medicare & Medicaid (CMS), HHS-OIG, OPM-OIG or other investigative agencies for administrative or criminal action. Serves as a liaison between the Special Investigations Unit and other company departments regarding company policies and procedures relating to appropriateness of claims submittals, payment protocols, and other issues relating to investigations.

Proactively pursues the detection and prevention of payment of fraudulent claims. Educates company employees, subscribers and providers regarding detection and prevention of health care fraud – all in service of creating a person-focused health care experience.

Can you see yourself as the bridge between complex fraud detection and educating others on how to prevent it from happening in the first place? Are you ready to use your analytical skills to ensure every healthcare dollar is spent appropriately, making the system work better for everyone? Then this role may be the perfect fit.

• Bachelor's Degree, Program Certification (i.e. Fraud Examiner or Criminal Justice), or successful completion of law enforcement academy, with two years of job related experience or equivalent combination of education and work related experience.
• Certified Professional Coder (CPC) certification preferred
• Experience with CMS and HHS-OIG/FBI or similar agencies preferred
• Current RN or LPN licensure preferred

• Extensive knowledge of medical procedures, terminology, and investigations, with experience in third party payer or independent health services contracting desired, along with investigative skills and exposure to the criminal justice system
• Proficient with Microsoft Office software programs and demonstrated ability to handle confidential information, multiple tasks, and work independently with minimal supervision while functioning within corporate structure
• Excellent written, oral and interpersonal communication skills with proven ability to coordinate activities diplomatically and persuasively across varying levels of management, staff, external agencies and medical professionals
• Strong analytical, organizational and problem-solving abilities with demonstrated maturity, tact and composure in stressful or confrontational situations
• Knowledge of state codes and regulations pertaining to health care and insurance industries, including legal terminology and procedures
• Must have personal, reliable transportation, valid driver's license and proof of automobile insurance for on-site audits and investigations, with ability to work flexible schedules to accommodate investigation needs
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

• Receives, analyzes and coordinates fraud and abuse complaints from internal sources (customer services, claims processing, underwriting, professional affairs) and external sources (members,…