Qureos Mentor

PacificSource Health Plans

<div><h1 class="jobSectionHeader">Looking for a way to make an impact and help people?</h1>
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person&rsquo;s talents and strengths.
The Senior Fraud, Waste and Abuse Investigator manages work related to fraud, waste and abuse audits and investigations across several independent and specialized teams. Functions include, conducting in depth investigations making decisions and recommendations on case direction, scope and timing; collaborating with managers and staff in Claims, Provider Network, Appeals and Grievances, Finance, Utilization Management and Analytics throughout the audit lifecycle; ensuring audit compliance with state and federal laws and regulations, contract requirements and company policies and procedures as they pertain to fraud, waste and abuse.
Essential Responsibilities:
<ul><li>Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims,</li><li>
Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.</li><li>
Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.</li><li>
Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.</li><li>
Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.</li><li>
Attend and participate in regional FWA Task Force and other state or federal meetings.</li><li>
Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies.</li><li>
Ensure regulatory reporting is developed, accurate, and submitted timely.</li><li>
Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.</li><li>
Develop and conduct internal FWA related training.</li><li>
Collaborate with government agencies during audits, investigations and Requests for Information (RFI).</li><li>
Present and discuss case findings and recommendations in case review meetings with department and company management.</li><li>
Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.</li><li>
Coordinate and manage the production of investigative materials in support of, settlement negotiations.</li></ul>
Supporting Responsibilities:
<ul><li>Meet department and company performance and attendance expectations.</li><li>
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.</li><li>
Perform other duties as assigned.</li></ul>
SUCCESS PROFILE
Work Experience: Minimum of 5 years of experience with complex healthcare fraud investigations required. Experience facilitating audit activities across specialized teams required. Experience navigating case management, claims and OSINT platforms preferred.
Education, Certificates, Licenses: Bachelor&rsquo;s degree in business administration, criminal justice, or related field required. Candidates with an associate&rsquo;s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered. Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required.
Knowledge: Strong working knowledge of investigative techniques and procedures as they relate to health care fraud, waste and abuse is required. Ability to gain a thorough understanding of PacificSource compliance initiatives. Respond timely to regulatory inquiries. Maintain sufficient reference materials to adequately research compliance issues. Ability to organize large complex investigative audits that involve working with multi-functional teams under strict deadlines. Ability to communicate effectively with all levels of the organization, federal and state agencies, providers, and members, both verbally and in writing. Working knowledge of legal and medical terminology. Ability to read, interpret, and apply the complex language and ideas found in provider contracts, case law, criminal and civil statues. Ability to work under time pressures, and remain professional in emotionally charged situations. Computer proficiency in a Windows environment, including Microsoft Office Suite.
Competencies
Adaptability
Building Customer Loyalty
Building Strategic Work Relationships
Building Trust
Continuous Improvement
Contributing to Team Success
Planning and Organizing
Work Standards
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.
Skills:
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork
Compensation Disclaimer
The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.
Base Range:
$65,296.83 - $111,004.62<h1 class="jobSectionHeader">
Our Values</h1>
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:<ul><li>
We are committed to doing the right thing.</li><li>
We are one team working toward a common goal.</li><li>
We are each responsible for customer service.</li><li>
We practice open communication at all levels of the company to foster individual, team and company growth.</li><li>
We actively participate in efforts to improve our many communities-internally and externally.</li><li>
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.</li><li>
We encourage creativity, innovation, and the pursuit of excellence.</li></ul>
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.</div>

Senior Fraud, Waste and Abuse (FWA) Investigator

<div><h1 class="jobSectionHeader">Looking for a way to make an impact and help people?</h1>
Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person&rsquo;s talents and strengths.
The Payment Integrity and Fraud, Waste and Abuse (FWA) Team Lead is responsible for overseeing the daily operations of PacificSource&rsquo;s Payment Integrity and FWA programs. This role provides leadership for Payment Integrity and FWA activities while supporting the development and execution of pre-payment and post-payment initiatives designed to ensure payment accuracy, regulatory compliance, and responsible stewardship of healthcare resources. The Team Lead serves as a subject matter expert in payment integrity operations, fraud prevention, audit activities, provider recoveries, and regulatory requirements. This position works closely with Claims, Compliance, Finance, Provider Relations, and external vendors to identify opportunities for cost avoidance, overpayment recovery, process improvement, and program effectiveness.
Essential Responsibilities:
<ul><li>Provide direct supervision, coaching, performance management, and professional development for assigned Payment Integrity and FWA staff.</li><li>
Supervise and direct payment integrity claims adjustment activities, ensuring timely and accurate implementation of claim corrections, recoveries, and financial adjustments.</li><li>
Oversee recovery inventory management and ensure identified overpayments, audit findings, and recovery opportunities are appropriately processed, tracked, and resolved.</li><li>
Coordinate daily work activities, workload prioritization, inventory management, and resource allocation across payment integrity functions.</li><li>
Support the execution and on-going operations of pre-payment and post-payment payment integrity programs, including audits, claims reviews, recoveries, and fraud prevention activities.</li><li>
Oversee the investigation, tracking, documentation, and resolution of potential fraud, waste, and abuse referrals and cases.</li><li>
Monitor payment integrity performance metrics and recovery results and prepare reports for leadership, compliance committees, and regulatory agencies as needed.</li><li>
Implement and maintain payment integrity policies, procedures, workflows, and operational controls.</li><li>
Ensure compliance with applicable federal and state regulations, CMS requirements, contractual obligations, and internal policies.</li><li>
Serve as a primary operational liaison between Payment Integrity, Compliance, Claims Operations, Provider Relations, Finance, and Special Investigations functions.</li><li>
Coordinate day to day operational activities with external vendors supporting audit, recovery, analytics, and fraud detection programs and monitor adherence to established service levels.</li><li>
Review audit findings, recovery opportunities, and investigative outcomes to ensure consistency, accuracy, and adherence to established standards.</li><li>
Support preparation and submission of regulatory reporting requirements related to fraud, waste, abuse, and payment integrity activities.</li><li>
Participate in internal and external audits and assist with corrective action planning and implementation.</li><li>
Identifying emerging risks, payment vulnerabilities, billing trends, and opportunities for program improvement and escalate recommendations to leadership.</li><li>
Lead or participate in departmental projects, process improvement initiatives, and cross-functional workgroups.</li><li>
Actively participate as a key member of management and leadership meetings.</li><li>
Represent Payment Integrity on internal committees and workgroups as assigned.</li><li>
Coordinate business activities by maintaining collaborative partnerships with key departments.</li><li>
Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.</li><li>
Actively participate as a key team member in department meetings.</li><li>
Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.</li></ul>
Supporting Responsibilities:
<ul><li>Participate in compliance and operational initiatives as needed.</li><li>
Assist with training and education efforts related to payment integrity and FWA prevention.</li><li>
Meet department and company performance and attendance expectations.</li><li>
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.</li><li>
Perform other duties as assigned.</li></ul>
SUCCESS PROFILE
Work Experience: Minimum of 4 years of senior-level healthcare operations, payment integrity, fraud prevention, claims auditing, claims administration, or related experience required. Prior supervisory experience preferred.
Education, Certificates, Licenses: Bachelor&rsquo;s degree required. Candidates with an associate&rsquo;s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.
Knowledge: Knowledge of healthcare claims processing, reimbursement methodologies, coding systems, and payment integrity concepts. Knowledge of fraud, waste, and abuse regulations and investigative practices. Understanding of Medicare, Medicaid, and commercial health plan regulatory requirements. Knowledge of ICD-10, CPT, HCPCS, DRG, and related reimbursement methodologies. Strong analytical, problem-solving, and decision-making skills. Ability to interpret data, identify trends, and develop operational recommendations. Ability to communicate effectively with leadership, regulators, providers, vendors, and cross-functional business partners.
Skills: Communication (written/verbal), Listening (active), Critical thinking, Collaboration, Organizational skills/Planning and Organization, Accountable leadership, Influencing, Decision-making.
Competencies
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Customer Loyalty
Building Strategic Work Relationships
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.
Skills:
Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization
Compensation Disclaimer
The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.
Base Range:
$83,310.45 - $145,793.28<h1 class="jobSectionHeader">
Our Values</h1>
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:<ul><li>
We are committed to doing the right thing.</li><li>
We are one team working toward a common goal.</li><li>
We are each responsible for customer service.</li><li>
We practice open communication at all levels of the company to foster individual, team and company growth.</li><li>
We actively participate in efforts to improve our many communities-internally and externally.</li><li>
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.</li><li>
We encourage creativity, innovation, and the pursuit of excellence.</li></ul>
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.</div>

Payment Integrity and Fraud, Waste and Abuse Team Lead

Join PacificSource Health Plans and explore 3   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

PacificSource Health Plans

About Company

Senior Fraud, Waste and Abuse (FWA) Investigator

Senior Fraud, Waste and Abuse (FWA) Investigator

Payment Integrity and Fraud, Waste and Abuse Team Lead