Job Details

Are you ready for new challenges and new opportunities?

Join our team!

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all.

The Opportunity:

The 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. This position supports regulatory compliance activities including regulatory reporting, investigations and training and education requirements. Responsibilities include compiling, verifying and submitting reports, and analyzing general compliance, FWA and privacy incidents.

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.
• Prepares 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.
• Completes detailed and extensive investigations in adherence with AlohaCare's procedures and best practices.
• Conduct reviews of flagged claims and suspected FWA, identifying opportunities for improving payment accuracy and preventing FWA.
• Conduct outreach to physicians and office staff for medical records when needed to support review of flagged claims.
• Prepare referrals for preliminary investigations.
• Communicates investigation outcome to line of business personnel and partners to implement provider and other compliance/ SIU related edits when appropriate.
• Participates and reports updates to Fraud, Waste, Abuse Committee (FWAC).
• Provides fraud awareness training to internal stakeholders.
• Delivers presentations to internal and external customers on Fraud, Waste and Abuse and related subjects.

Required Competencies & Qualifications:

• 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.
• 1-3 years of related SIU Investigator experience.
• Must possess strong knowledge of healthcare billing / coding, health insurance reimbursement methodologies.
• Excellent written and verbal communications skills required.
• Strong analytical abilities to review and evaluate information.
• Strong proficiency in Excel with the ability to effectively decipher, analyze, and organize complex data.
• Ability to work independently and collaboratively in a fast-paced environment.
• Excellent organizational and time management skills required.

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.