CareOregon Hiring for Special Investigations Unit Manager at Portland, OR  Full Time

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, or Nevada.

Job Summary

This position manages and administers fraud, waste and abuse (FWA) for CareOregon and two wholly-owned Coordinated Care Organizations (CCOs) – Columbia Pacific CCO (CPCCO) and Jackson Care Connect CCO (JCC CCO). This includes leading, overseeing and/or performing fraud investigations and providing regular FWA reporting to all CareOregon CCOs. Additionally, this position manages internal staff and provides FWA oversight for Third-Party Administrative (TPA) activities CareOregon performs on behalf of the Health Share CCO.

Essential Responsibilities

Fraud, Waste and Abuse Management

• Manage the development and operation of an effective fraud, waste, and abuse program in accordance with CMS requirements and the Federal Sentencing Guidelines with guidance from department leadership, including:
  • Recommendation and implementation of FWA policies and the FWA annual plan
  • Periodic reporting to the organization’s Internal Compliance Committee and governing Board of Directors
  • Effective training and education
  • Establishment and maintenance of effective lines of communication at all levels of the organization (to include a non-compliance reporting hotline)
  • Development and oversight of effective system for routine FWA monitoring, auditing and identification of compliance risks
  • Collaboration with other departments to ensure compliance issues are reported to appropriate channels for investigation and resolution
  • Clear and specific policies, procedures and standards relating compliance monitoring activities.

• Ensure the timely completion of the annual FWA work plan and evaluate the corresponding work performed by department staff.
• Perform and manage FWA investigations conducted by CareOregon staff, affiliates, and business partners.
• Complete and file all required Medicare and Medicaid filings and/or responses for FWA.
• Manage the development of sufficient and accurate monthly FWA dashboards and corresponding summaries used to identify and monitor current compliance and trending of all FWA matters including case details and metrics.
• Identify potential areas of FWA vulnerability and risk; partner with department leadership in developing and implementing corrective action plans for resolution of problematic issues and provide general guidance on how to avoid or deal with similar situations in the future.
• Provide input into strategic planning and budget planning for the department.

Employee Supervision

• Manage team and recommend team direction and goals in alignment with the organizational mission, vision, and values.
• Identify work and staffing needs to meet work expectations; recruit and hire, using an equity, diversity, and inclusion lens.
• Plan, organize, schedule, and monitor work; ensure employees have information and resources to meet job expectations.
• Lead the development, communication, and oversight of team and individual goals; ensure goals, expectations, and standards are clearly understood by staff.
• Train, supervise, motivate, and coach employees; provide support toward employee development.
• Incorporate guidance from CareOregon equity tools into people leadership, planning, operations, evaluation, and decision making.
• Ensure team adheres to department and organizational standards, policies, and procedures.
• Evaluate employee performance and provide regular feedback to support success; recognize strong performance and address performance gaps and accountability (corrective action).
• Perform supervisory tasks in collaboration with Human Resources as needed.

Organizational Responsibilities

• Perform work in alignment with the organization’s mission, vision and values.
• Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization’s strategic goals.
• Adhere to the organization’s policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• As required by our Medicaid contract, the individual must be a professional investigator, paralegal, professional coder, or auditor with corresponding certification
• Minimum 5 years’ experience in compliance and/or audit, including minimum 2 years focused on fraud, waste, and abuse

Preferred

• Fraud, waste and abuse experience in Medicaid or Medicare

Knowledge, Skills and Abilities Required

Knowledge

• Advanced understanding of healthcare fraud, waste and abuse
• Strong knowledge of State and Federal compliance and FWA requirements for Medicare and Medicaid Programs
• Strong knowledge of investigative techniques, including interviews, data analytics, evidence gathering, case documentation
• Solid understanding of information and reporting systems
• Knowledge about how the functions of a business work and relate to one another to benefit the member by improving regulatory compliance

Skills and Abilities

• Strong research, investigative and problem-solving skills
• Strong interpersonal and motivational skills
• People leadership skills, including the ability to manage and coach team members
• Ability to facilitate learning opportunities in a variety of informal and formal settings
• Ability to make presentations to small and large groups
• Ability to think logically and creatively without undue influence from personal biases
• Ability to build conceptual models and communicate complex ideas effectively
• Ability to plan, organize, manage, and monitor work projects
• Ability to serve in an internal consulting role, assisting the organization’s management and staff in embracing our goal of “doing it right the first time” and being cognizant of the company’s commitments to its various partners and the need to achieve excellent results in our work product and processes

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Indoor/Office Community Facilities/Security Outdoor Exposure

Member/Patient Facing: No Telephonic In Person

Hazards: May include, but not limited to, physical and ergonomic hazards.

Equipment: General office equipment

Travel: May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

#Li-Remote

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment

Veterans are strongly encouraged to apply.

Equal opportunity employer. This company considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.