Siu Investigator

Let’s do great things, together!

Founded in Oregon in 1955, ODS, now Moda, is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.

The Moda Health Investigator has the duty and responsibility to support and conduct investigations in either an initiative-taking or reactive manner. The Investigator must have an elevated level of professionalism both internally and externally, possess strong time management skills and be able to work effectively without direct supervision. The incumbent will initiate, analyze, develop, and successfully complete investigations and support other team members as needed. Investigations will be conducted in accordance with company policies and procedures and in compliance with all applicable laws and regulations.
The incumbent will be responsible for supporting and coordinating efforts to recover erroneous payments made as a result of a claims processing error, misrepresentative billing, fraud, abuse or any other criminal act.

Follow the link below and complete an application for this position.
https://j.brt.mv/jb.do?reqGK=27719381&refresh=true

Benefits:

1. Medical, Dental, Vision, Pharmacy, Life, & Disability
2. 401K- Matching
3. FSA
4. Employee Assistant Program
5. PTO and Company Paid Holidays

Schedule:

• PST

Primary Functions

1. Manage investigative case load while performing multiple duties.
2. Assist with prepayment review of claims in Special Investigations Unit across multiple lines of business.
3. Obtain data from multiple internal systems in response to Requests for Information (RFIs) from law enforcement and health plan oversight agencies.
4. Perform quality work duties concurrently by prioritizing to meet deadlines.
5. Collect and preserve detailed information.
6. Document all stages of each investigation using tracking software, company and department procedures, templates, and forms.
7. Prepare detailed post-audit investigative reports.
8. Maintain in-depth working knowledge of auditing, coding, and investigative techniques.
9. Develop and maintain collaborative relationships with Moda, law enforcement agencies and other carriers’ auditing and anti-fraud professionals.
10. Manage highly confidential and sensitive information while ensuring compliance with the Company’s privacy policies.
11. Attend appropriate educational opportunities (NHCAA, AAPC and HFPP, ACFE) to keep apprised of developments in health care fraud.
12. Participate in special projects as assigned.

Requirements:

1. 5 – 10 years of investigative experience required; healthcare fraud experience and AHFI, CFE, and CPC preferred.
2. 2-5 years working knowledge of claims and customer service systems. Facets experience preferred.
3. Bilingual skills preferred.
4. Must obtain CPC coding credential within one year from date of hire.
5. Excellent written, oral, and interpersonal skills.
6. Must be detail oriented.
7. Proficiency with Microsoft applications to include Microsoft Excel and Word.
8. SAS experience a plus.
9. Ability to manage highly confidential and sensitive information while ensuring compliance with Company’s privacy policies.
10. Experience with report writing and business correspondence.
11. Analytical ability to identify problems, develop solutions and implement a chosen course of action.
12. Ability to coordinate activities with varying levels of management, staff, external agencies and medical professionals through strong verbal and written communications.
13. Demonstrated maturity and tact, with the ability to be diplomatic and persuasive in situations requiring those qualities.
14. Demonstrated ability to work independently, yet function within team and corporate structure.
15. Ability to prioritize and practice excellent time management skills.
16. Ability to maintain organization in all aspects of job.
17. Ability to travel as required, including occasional overnight stays.
18. Ability to tolerate stressful and/or confrontational situations and maintain composure.
19. Ability to work flexible work schedules to accommodate investigations scheduling and completion.
20. Knowledge of medical terminology and anatomy preferred.
21. Must have a valid driver’s license.

Together, we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law.
For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our humanresources@modahealth.com email.