Apply online at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving Hawai`i’s low-income residents with free Medicaid and dual Medicare health insurance coverage. Our members include children, seniors and adults residing on all islands. We provide comprehensive benefits and managed care services with an emphasis on healthy living habits and preventive primary health care. Our approach is to meet the whole-person health and social needs of members. Through our community partnerships we offer innovative services such as connection to social service agencies, Native Hawaiian healing services and in-home primary care for qualified members. Our mission is to serve in the true spirit of aloha by ensuring and advocating for access to quality health care for all. We are Hawaii’s third-largest health plan and offer a wide network of quality primary care, specialists, hospitals, pharmacies and among many other providers across the state.

The Culture:

AlohaCare employees have a passion for helping Hawai`i’s most underserved communities. Our caring culture is fundamental to our company-wide team approach to providing high quality services. We support our employees with a supportive and positive work environment, healthy work-life balance, continuous communication, and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication.

AlohaCare’s comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program.

The Opportunity:

The Special Investigations Unit (SIU) Investigator is responsible for detection, identification, investigation and prevention of healthcare fraud, waste, and abuse as well as compliance investigations, including HIPAA privacy incidents. The SIU Investigator will utilize claims data within the SIU application, regulatory guidance and policies, and other sources to identify aberrant billing practices and other patterns. This position supports regulatory compliance activities including regulatory reporting, investigations and training and education requirements. Under general supervision, responsible for compiling, verifying and submitting reports, and analyzing general compliance, FWA and privacy incidents. Performs applicable follow up on corrective actions that result from compliance activities to ensure compliance with applicable federal and state laws, contract requirements, and internal policies and procedures. Provides high quality customer service using professionalism, confidentiality and good judgment. The SIU Investigator is responsible for maintaining and fostering an environment that enhances and promotes regulatory compliance.

Primary Duties and Responsibilities:

• Conducts Fraud, Waste and Abuse (FWA) and related compliance investigations.
• Develops and maintains routine and ad hoc Compliance reporting, conducts detailed analysis, and summarizes results for internal and external stakeholders.
• Analyzes compliance and FWA cases for root cause, trends and tracks data to translate findings and develop processes for improvement or investigation.
• Prepare accurate, timely, unbiased and detailed written reports and case summaries in compliance with corporate standard operating procedures and guidelines documenting investigative results.
• Updates corporate SIU case management system with accurate, current, and thorough investigative notes, reports and summaries.
• Independently develops and executes appropriate investigation strategy for assigned cases. Lead in-depth interviews of participants, witnesses or affected parties.
• Completes detailed and extensive investigations in adherence with AlohaCare’s procedures and best practices. Gathers and secures evidence and makes determinations regarding potential recoveries.
• Conduct reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA.
• Review claims flagged by Vendor with do not pay recommendations and suspected FWA cases in an accurate, efficient and timely manner.
• Conduct outreach to physicians and office staff for medical records when needed to support review of flagged claims.
• Prepare referrals for preliminary investigations, including but not limited to: Requesting medical records, creating forms, reports and updating logs.
• Assist other compliance investigators with preliminary investigation activity.
• Communicates investigation outcome to line of business personnel and partners to implement provider and other compliance/ SIU related edits when appropriate.
• Proactively partner with line of business personnel to generate referrals. Partner with various SIU and line of business personnel to determine merits of initiating organized scheme investigations.
• May evaluate incoming referrals to determine appropriate SIU investigation assignments. Research and prepares cases for clinical and legal review.
• Participates and reports updates to Fraud, Waste, Abuse Committee (FWAC).
• Provides fraud awareness training to internal stakeholders. Provides on the job training to new Investigators and provides guidance for less experienced or skilled Investigators. Assists Investigators in identifying resources and best course of action on investigations.
• Facilitates the recovery of inappropriate payments as a result of fraud matters.
• Assists in maintaining compliance with timely completion and reporting of State and Federal deliverables
• Cooperates with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters. May be required to provide testimony during civil and criminal proceedings.
• May represent the Company and actively participate in industry association meetings by providing training to industry SIU personnel or law enforcement. Shares intelligence and trends with SIU and other internal stakeholders.
• Delivers presentations to internal and external customers on Fraud, Waste and Abuse and related subjects.
• All other duties assigned.
• Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
• Responsible for maintaining AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality. Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements:

• Bachelor’s degree in related field of study or combination of education, professional training and/or work experience which demonstrates the capability to perform the functions of the position.
• Minimum of 1 year of related SIU Investigator experience.
• Must possess strong knowledge of healthcare billing / coding, health insurance reimbursement methodologies, including ICD-10 and HCPCS coding.
• Strong analytical abilities to review and evaluate information such as claims data, patterns and other supporting information related to case allegations details.
• Intermediate level of knowledge with local, state/federal laws and regulations pertaining to healthcare fraud, waste, and abuse.
• Curious, detailed-oriented and mindset required.
• Research skills.
• The ability to navigate and understand claims data and various database in order to develop and document case allegations is required.
• The ability to obtain information from others and deliver information in a concise and clear manner.
• Proficient knowledge of spreadsheets/graphics, presentation, and databases.
• Understanding of investigational processes and standards.
• Ability to interpret an extensive variety of technical instructions and deal with several abstract and concrete variables.
• Achieves results, builds trust, communicate effectively, customer and quality focused.
• Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization.
• Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
• Professional telephonic etiquette skills.
• Ability to solve problems, analyze, think critically and make good judgment.
• Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills.
• Able to work independently with minimal supervision.
• Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.

• Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
• Data entry experience with a high degree of accuracy and attention to detail.

• Intermediate skills in Microsoft Programs: Word, Excel, Outlook and PowerPoint.
• Experience in the operation of general office equipment to include PC, fax/copy machine and phone system.

Preferred Requirements:

• Proficiency in business intelligence software and reporting tools including, but are not limited to, MS SQL Server Components and Microsoft SQL, Oracle, and Business Objects (Crystal Reports, Web Intelligence, OLAP, Universes and Xcelsius).
• Strong claims knowledge.
• Ability to write reports and create workflows.
• Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
• Certified in Professional Coder (CPC) is a plus.
• Demonstrated knowledge and experience of Medicare, Medicaid, and other government programs.

Mental, Physical and Environmental Demands:

• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.
• In office working environment.
• Field working environment.
• May require prolonged sitting- up to 4 hours.
• Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.?

Salary Range: $61,000 - $83,000 annually

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.