Special Investigations Unit Investigator

Special Investigations Unit Investigator

This position is responsible for administering the fraud, waste, and abuse (FWA) duties for Care Oregon and its affiliated lines of business. Core work includes ensuring effective measures are in place to prevent, detect, and correct instances of fraud, waste, and abuse, conducting investigations, and providing FWA reporting.

• Assist in developing and operating an effective FWA program in accordance with CMS, OHA/OHP, and applicable laws.
• Perform routine FWA investigations, audits, and corrective actions; maintain documents and provide routine updates.
• Prepare audit findings reports and recommend corrective actions or improvements.
• Prepare, proofread, and distribute correspondence, forms, and other specialized confidential information.
• Respond to routine and ad‑hoc requests from external regulatory agencies, including annual reviews, quarterly reports, and one‑off requests.
• Prepare routine and ad‑hoc reports for internal and external leaders, committees, and governing bodies.
• Assist in developing and maintaining an organized, methodical documentation system for new and existing FWA regulatory requirements.
• Review and recommend policy and procedure revisions that support the FWA/SIU program.
• Attend internal and external FWA and compliance‑related meetings as assigned.
• Assist in providing effective FWA training and education to staff, both internal and external.
• Educate providers on appropriate documentation and coding.
• Participate in FWA program‑related risk assessment and mitigation processes.
• Meet departmental metrics for key performance indicators.

• Indoor/office work environment.
• Occasional travel may be required.
• Work from home allowed.
• Ability to bend and speak clearly for at least 3 hours per day.
• Ability to learn, focus, understand, evaluate information, and determine appropriate actions.
• Ability to accept direction and feedback, and manage stress.
• Ability to see, read, and hear for at least 6 hours per day.
• Ability to perform repetitive finger and wrist movements for 3–6 hours per day.
• Ability to work effectively with diverse individuals and groups.

• Strong research, investigative, and problem‑solving skills.
• Strong communication skills, including written, verbal, and listening.
• Effective computer skills, including MS Office Suite.
• Strong interpersonal and motivational skills.
• Ability to think logically and creatively without undue personal bias.
• High professionalism and confidentiality.
• Ability to plan, organize, manage, and monitor work projects.
• Ability to facilitate learning opportunities in informal and formal settings.
• Ability to make presentations to small and large groups.

• Understanding of healthcare fraud, waste, and abuse.
• Understanding the difference between State Medicaid programs and Medicare.
• Knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid.
• Knowledge of investigative techniques including interviews, data analytics, evidence gathering, and case documentation.
• Understanding of information systems.

• Minimum 2 years’ experience in FWA, compliance, and/or audit within a highly regulated industry.

• Oregon Medicaid experience or health plan experience.
• CPC (Certified Professional Coder), RHIT (Registered Health Information Technician), or CFE (Certified Fraud Examiner).

• Perform work in alignment with the organization's mission, vision, and values.
• Support the organization’s commitment to equity, diversity, and inclusion.
• Strive to meet annual business goals and support strategic objectives.
• Adhere to the organization's policies, procedures, and compliance needs.
• Perform other duties as needed.

We offer a strong total rewards program, including competitive pay, bonus opportunities, and a comprehensive benefits package. Eligible employees receive health, dental, vision, life, disability insurance, as well as retirement plan contributions, PTO, and paid state sick time. Additional benefits may include wellness programs, employee assistance program, and supplemental benefits.

Equal Opportunity Employer
:
Care Oregon is an equal opportunity employer. The organization selects the best individual for the job based upon job‑related qualifications, regardless of race, color, religion, sexual orientation, national origin, gender, gender identity, gender expression, genetic information, age, veteran status, ancestry, marital status, or disability. Reasonable accommodations are made for qualified applicants or employees with disabilities unless they impose undue hardship.