Provider Fraud Investigator 3 (I3DAIO)

Provider Fraud Investigator 3

This 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.

The Opportunity

Protect Apple Health from fraud and help make sure public dollars go to the care people need. The Special Investigations Unit (SIU) in HCAs Division of Audit Integrity and Oversight (DAIO) is seeking an Investigator 3 to evaluate allegations of provider fraud in Washingtons 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 Generals Office managed care organizations and federal partners to stop fraudulent billing.

Key Responsibilities

• 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 Agencys Hot Tips or other referral platforms.
• Manage each case assignment throughout the life of the case.
• Refer credible allegations of fraud the Attorney Generals 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 Youll Love This Role

• Youll protect public dollars and the integrity of care for the people who rely on Apple Health.
• Youll work complex cases alongside the Attorney Generals Office managed care organizations and federal partners such as HHS-OIG and the FBI.
• Youll have the independence to design your own Investigative strategies on a small specialized team.
• Youll 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

Experience may have been gained through paid or unpaid activities. Please ensure any relevant experience defined below is outlined in your cover letter resume and application.

• 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 Generals 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. such as Managed Care Organization (MCO) allegation reviews to determine the credibility of fraud indicators.
• 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 youve 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

While these are not required having them may help you stand out as an applicant.

• 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.

About the Washington State Health Care Authority

Better Health. Better Care. A Healthier Washington.

At HCA we work to ensure people across Washington have the opportunity to be as healthy as possible. As the States largest health care purchaser and behavioral health authority HCA serves nearly 3 million Washington residents through Apple Health (Medicaid) Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs and behavioral health services. Through this work HCA purchases and coordinates care coverage supports behavioral health prevention treatment crisis response and recovery and helps strengthen access to high-quality care across Washington.

More than a benefits package: We want our employees to have the support flexibility and benefits they need to do their best work and build a career that works for their life. As a Washington State HCA employee youll have access to a comprehensive benefits package that supports your health financial well-being and work-life balance. Our benefits are designed to support you today while helping you plan for the future. Learn more about HCA by visiting the Voices of HCA and the Who we are section of our website.

Your total compensation is more than your paycheck:

• Remote work and flexible schedules
• Medical dental vision and basic life insurance
• Paid vacation sick leave and 12 paid holidays
• Paid Family and Medical Leave (PFML)
• Retirement options to plan for the future
• Training and professional development opportunities
• Employee wellness programs
• Learn more about Washington State Employee Benefits

Work location and schedule: This is a full-time 40-hour-per-week remote position. Our standard business hours are Monday through Friday 8 a.m. to 5 p.m. with alternative work schedules considered based on business needs and supervisor this role you will regularly collaborate with colleagues agency leaders state and federal partners and other external partners or customers. Occasional travel may be required for meetings training or other business needs. All employees are required to report to our Olympia office on their first and final day of employment.

Our commitment to an inclusive workplace: The Health Care Authority is an equal opportunity employer. We are committed to creating a workplace where employees are respected included and supported in bringing their experiences perspectives and ideas to work. Our commitment to inclusion is reflected in how we work together and serve the people of Washington. HCA also supports five voluntary employee led Employee Resource Groups (ERGs) which create opportunities for connection community learning and professional growth.

Application Directions

To be considered you must complete the online application in full and submit all required materials. Incomplete applications or applications missing required materials will not be considered. When completing your application please include the following required materials:

• Cover letter: describing your qualifications for this specific position
• Resume: that details your applicable experience and education.
• Three (3) professional references: References must be entered directly into the designated references section of your application. We require 3 professional references including at least one current or recent supervisor.

We encourage you to apply! If you meet the required qualifications for this position; we want to hear from you. Desired qualifications describe additional experience knowledge or skills that may be helpful in the role but they are not required to be considered for the position. We welcome applicants with different backgrounds experiences identities and perspectives.

Veterans: We value the experience and skill veterans bring to the workforce and encourage veterans transitioning service members and military spouses to apply. Eligible veterans may qualify for veterans preference in accordance with Washington State Law. If you are claiming veterans preference you must attach your applicable DD-214 documentation to your application. Please redact your social security number date of birth and any other sensitive information before uploading and attaching the document.

Need accommodations or have questions If you have questions need assistance with the application process require an accommodation or would like to request this posting in an alternative format please contact Lisa Fleming Human Resources Consultant (Recruiter) at and reference the recruitment title and job number in the subject line.

Technical support : Reach out to NEOGOV directly at 1- for technical support and login issues.

The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply.

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