Providence Health Plan caregivers are not simply valued – they’re invaluable. Join our team and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

Providence Health Plan is calling an Investigator, Special Investigation Unit who will:

• Support timely completion of compliance related audits and investigations of the Special Investigations Unit (SIU) at the Health Plan
• Collaborate with and learn from subject matter experts to identify, investigate and correct fraudulent and/or abusive billing and coding practices, which may advance in complexity with experience
• Leverage credible sources of information from Internet research in case preparation
• Proactively learns and applies data analysis related to fraud risk identification and prevention
• Able to manage a workload with multiple cases and audits simultaneously
• May assist Senior Investigator or SIU Director in developing, implementing and performing compliance related auditing and monitoring activities at the Health Plan
• Coordinate recovery of overpayments related to fraudulent and/or abusive billing and coding practices; keeps organized audit work papers that enables collaboration with external teams in the audit and recovery process
• Coordinate with parties with compliance accountabilities to facilitate corrective action completion and behavior change
• Provide education related to coding, medical record documentation requirements, healthcare compliance and fraud, waste and abuse to Health Plan staff, vendors and contracted providers/facilities
• Support team in peer review and delivery of quality work product, including integrating checks on their own work product
• Presents on fraud risk in a professional manner, in written and oral reports, tailored to providers, executives, members, and regulators
• Submit timely and professional reports of case findings to regulators, law enforcement, and internal business partners
• Provide training on fraud prevention to executives, caregivers, business partners, and members
• Supports timely processing of risk report intake triage, timely processing of prepay audit claims, and other compliance requirements

Please note the following important detail regarding this role:

• This position is affiliated with Providence Health Plan and will be tied to a location and compensation range in Beaverton, Oregon

Providence Health Plan welcomes 100% remote work for residents of the following States:

• Washington
• Oregon
• California

Required qualifications for this position include:

• Bachelor's Degree -OR- a combination of equivalent education and experience
• 5+ years coding experience at a healthcare provider, facility or health insurance company
• 2+ years fraud and abuse audit experience at a health plan, health insurance company, healthcare provider, facility or other relevant healthcare environment
• Project management experience, education program development experience and group presentation experience
• Experience in use of data mining software/tools

Preferred qualifications for this position include:

• Clinical background such as Registered Nurse (RN), Doctorate of Medicine (MD), or Doctor of Chiropractic (DC)
• Current certification as Certified Coding Professional (CPC)
• Current certification in health care fraud investigation, such as Accredited Healthcare Fraud Investigator (AHFI), Certification as an Internal Auditor (CIA), Healthcare Compliance certification (CHC), or equivalent
• Certification in Project Management or Agile (PMP, CSM, CSPO)
• Basic understanding of statistics and data analytics
• Basic understanding of analytics software (e.g.: SQL, Power BI, MS Access, Tableau, Alteryx) or a demonstrated interest in learning analytics software
• Advanced understanding of MS Excel and PowerPoint
• Professional communication skills, representing the SIU in verbal and written communications with executives, law enforcement, regulators, attorneys, physicians, members, etc.

Why Join Providence Health Plan?

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.