Providence Health & Services Investigator-External Audit Special Investigations Unit (SIU) in Beaverton, Oregon
Providence St. Joseph Health is calling an Investigator-External Audit Special Investigations Unit (SIU) to our location in Beaverton, OR.
In this position you will have the following responsibilities:
Collaborates with provider contract administration staff, systems administration staff, operations staff, quality medical management staff and provider relations and network development staff on fraud, waste and abuse issues and will actively seek changes required in Health Plan operations and claims adjudication system set up to prevent overpayments for fraudulent and/or abusive billing and coding practices on a pre-adjudication basis.
Works closely with Health Plan legal counsel on overpayment recoveries and provider contract terminations related to fraud, waste and abuse audits. This position frequently responds to document production requests from legal counsel in preparation for fair hearings and arbitrations and occasionally serves as a witness under oath in arbitrations related to fraud, waste and abuse activities.
Conduct fraud, waste and abuse audits in accordance with compliance and audit work plan and prepare detailed audit reports for management, legal counsel and providers.
Identify, investigate and resolve billing and coding related inquiries and complaints from beneficiaries, members, regulatory agencies and internal and external customers through demand for refund of overpayments and education to providers.
Perform data analysis of provider and member payment integrity issues and facilitate business process improvement to ensure health plan compliance.
Act as a resource on compliance issues or questions related to auditing and monitoring activities.
Perform audit activities, including on-site record reviews, at provider offices as required.
Participate in and coordinate Provider Appeals process specific to SIU overpayment demands.
Required qualifications for this position include:
Bachelor’s degree or equivalent combination of education and experience.
5 years coding experience with a healthcare provider, facility or health insurance company and current coding certification from the American Academy of Professional Coders (AAPC) and/or American Health and Information Management Association (AHIMA) (e.g., CPC, CPC-P, CPC-H, CCS, CCS-P) or will consider applicant who is eligible to obtain certification within first 6 months of hire.
2 to 5 years Fraud and Abuse audit experience in a health insurance company, healthcare provider, facility or other relevant healthcare environment.
Project management experience, education program development experience and group presentation experience.
Knowledge of Medicare conditions of participation, healthcare reimbursement regulations and provider contract language with ability to analyze implications is essential.
Extensive knowledge of coding conventions and payment rules as they apply to medical record keeping, billing of medical and surgical services and healthcare reimbursement systems.
Awareness of healthcare regulatory trends, including the OIG workplan and other healthcare compliance enforcement priorities.
Intermediate understanding of healthcare reimbursement issues involved in facility, supplier, provider contracts and an extensive understanding of all types of coding applications.
Understanding of audit procedures (e.g., data collection and sampling methodologies).
Ability to interact appropriately with all levels of management, especially physicians.
Excellent oral and written communication and interpersonal skills.
Strong analytical and mathematical skills.
Demonstrated organizational and problem-solving skills.
Experience in use of data mining software/tools.
Must be proficient in MS Office Suite (Word, Excel, Access, PowerPoint, Publisher, Outlook). Occasional use of portable scanner, fax machine, copier, etc.
Preferred qualifications for this position include:
Current certification as an Accredited Healthcare Fraud Investigator (AHFI).
Certification as an Internal Auditor or Healthcare Compliance certification.
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
We offer a full comprehensive range of benefits - see our website for details
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Health Plan/Insurance Nursing
Req ID: 212475