Provider Fraud Investigator 3 (I3/DAIO)

Summary

Provider Fraud Investigator 3This is a full-time permanent, remote position. Employees may occasionally be asked to attend an in-person meeting or event based on business needs. All HCA employees are required to be Washington state residents upon their first day of employment.Protect Apple Health from fraud and help make sure public dollars go to the care people need. The Special Investigations Unit (SIU) in HCA's Division of Audit, Integrity, and Oversight (DAIO) is seeking an Investigator 3 to evaluate allegations of provider fraud in Washington's Medicaid program. As one of three professional Investigators in the unit, you will determine whether allegations are credible, build cases from start to finish, and work closely with the Attorney General's Office, managed care organizations, and federal partners to stop fraudulent billing.Key responsibilities include:Maintain expert knowledge and understanding of Federal regulations and sub-regulatory guidance, State laws and regulations, Agency policy, rules, and contracts, and other relevant criteria.Design and implement investigative strategies using independent judgment to formulate a plan of action and direction in complex scenarios.Research and/or investigate leads/complaints/referrals received through the Agency's Hot Tips or other referral platforms.Manage each case assignment throughout the life of the case.Refer credible allegations of fraud the Attorney General's Medicaid Fraud and Abuse Division (MFAD) for civil and criminal investigation and prosecution.Supports fraud investigations conducted by the MFAD.Initiates payment suspension protocols when MFCD accepts a credible allegation of fraud referral.Communicates the results of each investigation to appropriate stakeholders through formal and informal reports, memorandums, and/or case presentations.Review managed care entity (MCE) allegation and fraud referral deliverables.Facilitate MCO allegation meetings to determine if allegations appear credible.Attend de-confliction meetings to ensure active fraud cases are known to DAIO.Participate in bimonthly FACT meetings to coordinate cases and leads.Participate in multi-agency activities coordinating fraud investigation efforts. Participants may include MFAD, MCOs, Department of Health, Department of Social and Health Services, and various federal partners, i.e., Health and Human Services Office of the Inspector General (HHS-OIG), Federal Bureau of Investigations (FBI), etc.Why you'll love this role:You'll protect public dollars and the integrity of care for the people who rely on Apple Health.You'll work complex cases alongside the Attorney General's Office, managed care organizations, and federal partners such as HHS-OIG and the FBI.You'll have the independence to design your own investigative strategies on a small, specialized team.You'll work remotely, with occasional on-site visits as cases require.What you bring:You are a curious, objective investigator who follows the evidence wherever it leads. You stay professional and unbiased under pressure, keep meticulous records, and draw sound conclusions from complex data and documentation. You build strong working relationships with clinical staff, legal partners, and managed care organizations, and you explain your findings clearly, whether in a written report or a case presentation. You hold yourself to the highest standards of ethical conduct.Required qualifications:Regulatory mastery: Deep, fluent knowledge of Federal regulations, sub-regulatory guidance, State laws, Agency policies, rules, and managed care contracts.Fraud referral & prosecution standards: Thorough understanding of what constitutes a "credible allegation of fraud" (CAF) and the specific legal thresholds required to refer cases to the Attorney General's Medicaid Fraud Control Division (MFCD/MFAD).Legal/statutory enforcement: Demonstrated competency in executing high-stakes administrative actions, such as initiating payment suspension protocols and coordinating joint civil/criminal investigations.Autonomous strategy design: Demonstrated ability to use independent judgment to formulate, adapt, and execute complex investigative plans of action from scratch.End-to-end case management: Demonstrated understanding of the full lifecycle management of complex cases, from intake (e.g., Hot Tips, referrals) to final resolution and reporting.Onsite & field operations: Proficiency in planning and conducting secure, objective onsite investigations of provider facilities or managed care entities (MCEs).Healthcare data mining: Advanced competency in querying, analyzing, and mining complex claims data, billing codes, and encounter records to identify anomalous or fraudulent billing patterns.Evidence-based evaluation: Demonstrated ability to objectively review provider billing records, electronic health records (EHR), and MCE financial records, while effectively collaborating with clinical staff to synthesize technical medical evidence.Root-cause & vulnerability analysis: Demonstrated ability to look beyond individual fraud cases to identify systemic policy gaps or IT system vulnerabilities that enable fraudulent practices.Forensic interviewing: Advanced tactical interviewing skills tailored to diverse audiences, including medical providers, corporate executives, provider staff, and program clients (e.g., Apple Health clients).Objective fact-finding: A steadfast commitment to professional objectivity, ensuring all findings are strictly anchored in verifiable facts and gathered evidence, entirely free from bias.Cross-contamination mitigation: Competency in managing fraud alerts across multiple networks (e.g., notifying other MCOs and shifting focus to fee-for-service billing when a multi-layered fraud scheme is discovered).Executive & legal reporting: Excellence in drafting formal investigative reports, legal memorandums, and case presentations suitable for stakeholders, agency leadership, and prosecutors.Required competencies:Equity lens – All HCA employees are required to consider equity in their decisions, processes, and day-to-day work, including how their work may affect the people and communities we serve.The ability to take action to learn and grow – You take action to learn and grow by seeking new perspectives, learning from experiences, and using what you've learned to continuously improve how you work and serve others.The ability to take action to meet the needs of others – You take action to meet the needs of others by listening, understanding different perspectives, and responding with care, respect, and solutions that support the people of the communities we serve.Preferred qualifications:Previous professional experience as a Medical Assistant Program Specialist 1, Health Care Program Consultant, or Medical Assistance Specialist 4 or 5.Working experience in audits or reviews of healthcare claims, i.e., licensed professional (physician, ARNP, dental), pharmacy, durable medical equipment, ambulance, behavioral health, home health services, nursing home.Working knowledge of medical terminology and interpretation of health care documentation.Demonstrated experience in data mining, data interpretation, and data analysis.Working experience conducting medical record reviews and ability to interpret and apply Federal and State regulations, coding and billing requirements.Proficient in the application of ICD-10, CPT, and HCPCS coding principles.Proficient in the use of Microsoft software, including Word, Excel, and Access.Ability to lead teams and build consensus.Working with knowledge of ProviderOne, or other Medicaid Management Information System (MMIS).Knowledge of healthcare auditing concepts and principles.An advanced degree in public health, public administration, social work, or closely related field.About the Division of Audit, Integrity, and Oversight (DAIO):DAIO is responsible for providing oversight and helping ensure the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries; the identification, prevention, and investigation of fraud, waste, and abuse; grant subrecipient monitoring; managed care organization contract compliance; PEBB/SEBB enrollment compliance; and the oversight of behavioral health and recovery spending.

Job Description

Provider Fraud Investigator 3This is a full-time permanent, remote position. Employees may occasionally be asked to attend an in-person meeting or event based on business needs. All HCA employees are required to be Washington state residents upon their first day of employment.Protect Apple Health from fraud and help make sure public dollars go to the care people need. The Special Investigations Unit (SIU) in HCA's Division of Audit, Integrity, and Oversight (DAIO) is seeking an Investigator 3 to evaluate allegations of provider fraud in Washington's Medicaid program. As one of three professional Investigators in the unit, you will determine whether allegations are credible, build cases from start to finish, and work closely with the Attorney General's Office, managed care organizations, and federal partners to stop fraudulent billing.Key responsibilities include:Maintain expert knowledge and understanding of Federal regulations and sub-regulatory guidance, State laws and regulations, Agency policy, rules, and contracts, and other relevant criteria.Design and implement investigative strategies using independent judgment to formulate a plan of action and direction in complex scenarios.Research and/or investigate leads/complaints/referrals received through the Agency's Hot Tips or other referral platforms.Manage each case assignment throughout the life of the case.Refer credible allegations of fraud the Attorney General's Medicaid Fraud and Abuse Division (MFAD) for civil and criminal investigation and prosecution.Supports fraud investigations conducted by the MFAD.Initiates payment suspension protocols when MFCD accepts a credible allegation of fraud referral.Communicates the results of each investigation to appropriate stakeholders through formal and informal reports, memorandums, and/or case presentations.Review managed care entity (MCE) allegation and fraud referral deliverables.Facilitate MCO allegation meetings to determine if allegations appear credible.Attend de-confliction meetings to ensure active fraud cases are known to DAIO.Participate in bimonthly FACT meetings to coordinate cases and leads.Participate in multi-agency activities coordinating fraud investigation efforts. Participants may include MFAD, MCOs, Department of Health, Department of Social and Health Services, and various federal partners, i.e., Health and Human Services Office of the Inspector General (HHS-OIG), Federal Bureau of Investigations (FBI), etc.Why you'll love this role:You'll protect public dollars and the integrity of care for the people who rely on Apple Health.You'll work complex cases alongside the Attorney General's Office, managed care organizations, and federal partners such as HHS-OIG and the FBI.You'll have the independence to design your own investigative strategies on a small, specialized team.You'll work remotely, with occasional on-site visits as cases require.What you bring:You are a curious, objective investigator who follows the evidence wherever it leads. You stay professional and unbiased under pressure, keep meticulous records, and draw sound conclusions from complex data and documentation. You build strong working relationships with clinical staff, legal partners, and managed care organizations, and you explain your findings clearly, whether in a written report or a case presentation. You hold yourself to the highest standards of ethical conduct.Required qualifications:Regulatory mastery: Deep, fluent knowledge of Federal regulations, sub-regulatory guidance, State laws, Agency policies, rules, and managed care contracts.Fraud referral & prosecution standards: Thorough understanding of what constitutes a "credible allegation of fraud" (CAF) and the specific legal thresholds required to refer cases to the Attorney General's Medicaid Fraud Control Division (MFCD/MFAD).Legal/statutory enforcement: Demonstrated competency in executing high-stakes administrative actions, such as initiating payment suspension protocols and coordinating joint civil/criminal investigations.Autonomous strategy design: Demonstrated ability to use independent judgment to formulate, adapt, and execute complex investigative plans of action from scratch.End-to-end case management: Demonstrated understanding of the full lifecycle management of complex cases, from intake (e.g., Hot Tips, referrals) to final resolution and reporting.Onsite & field operations: Proficiency in planning and conducting secure, objective onsite investigations of provider facilities or managed care entities (MCEs).Healthcare data mining: Advanced competency in querying, analyzing, and mining complex claims data, billing codes, and encounter records to identify anomalous or fraudulent billing patterns.Evidence-based evaluation: Demonstrated ability to objectively review provider billing records, electronic health records (EHR), and MCE financial records, while effectively collaborating with clinical staff to synthesize technical medical evidence.Root-cause & vulnerability analysis: Demonstrated ability to look beyond individual fraud cases to identify systemic policy gaps or IT system vulnerabilities that enable fraudulent practices.Forensic interviewing: Advanced tactical interviewing skills tailored to diverse audiences, including medical providers, corporate executives, provider staff, and program clients (e.g., Apple Health clients).Objective fact-finding: A steadfast commitment to professional objectivity, ensuring all findings are strictly anchored in verifiable facts and gathered evidence, entirely free from bias.Cross-contamination mitigation: Competency in managing fraud alerts across multiple networks (e.g., notifying other MCOs and shifting focus to fee-for-service billing when a multi-layered fraud scheme is discovered).Executive & legal reporting: Excellence in drafting formal investigative reports, legal memorandums, and case presentations suitable for stakeholders, agency leadership, and prosecutors.Required competencies:Equity lens – All HCA employees are required to consider equity in their decisions, processes, and day-to-day work, including how their work may affect the people and communities we serve.The ability to take action to learn and grow – You take action to learn and grow by seeking new perspectives, learning from experiences, and using what you've learned to continuously improve how you work and serve others.The ability to take action to meet the needs of others – You take action to meet the needs of others by listening, understanding different perspectives, and responding with care, respect, and solutions that support the people of the communities we serve.Preferred qualifications:Previous professional experience as a Medical Assistant Program Specialist 1, Health Care Program Consultant, or Medical Assistance Specialist 4 or 5.Working experience in audits or reviews of healthcare claims, i.e., licensed professional (physician, ARNP, dental), pharmacy, durable medical equipment, ambulance, behavioral health, home health services, nursing home.Working knowledge of medical terminology and interpretation of health care documentation.Demonstrated experience in data mining, data interpretation, and data analysis.Working experience conducting medical record reviews and ability to interpret and apply Federal and State regulations, coding and billing requirements.Proficient in the application of ICD-10, CPT, and HCPCS coding principles.Proficient in the use of Microsoft software, including Word, Excel, and Access.Ability to lead teams and build consensus.Working with knowledge of ProviderOne, or other Medicaid Management Information System (MMIS).Knowledge of healthcare auditing concepts and principles.An advanced degree in public health, public administration, social work, or closely related field.About the Division of Audit, Integrity, and Oversight (DAIO):DAIO is responsible for providing oversight and helping ensure the integrity of our healthcare purchasing and grant activities. This includes auditing medical and other benefit providers and beneficiaries; the identification, prevention, and investigation of fraud, waste, and abuse; grant subrecipient monitoring; managed care organization contract compliance; PEBB/SEBB enrollment compliance; and the oversight of behavioral health and recovery spending.