Job Description| JOB TITLE | Sr. Program Integrity Investigator | REPORTS TO | Compliance Officer |
| STATUS | FT, -Exempt | WAGE RANGE | 19 (2024) |
| DEPARTMENT | Compliance | WORK LOCATION | Remote / Hybrid (travel to community for business need may be required) |
| POSITION PURPOSE |
| Umpqua Health Alliance is seeking a seasoned Senior Program Integrity Investigator to lead complex fraud, waste, and abuse (FWA) investigations. This role is responsible for independently managing high-risk investigations, coordinating with regulatory and law enforcement agencies, and driving recovery and corrective action. The ideal candidate holds an AHFI designation and brings at least six years of experience in healthcare FWA investigations within a health plan, SIU, or regulatory agency. |
| ESSENTIAL JOB RESPONSIBILITIES |
- Conduct complex FWA investigations involving providers, members, and vendors, managing all phases from intake to resolution.
- Analyze claims, encounter data, medical records, and financial transactions to identify patterns of fraud, waste, or abuse.
- Apply state and federal healthcare regulations, including CMS and OHA guidelines, to validate findings and determine next steps.
- Lead interviews with providers, members, and internal staff; coordinate with law enforcement or regulatory bodies as appropriate.
- Prepare comprehensive investigation reports detailing findings, recovery recommendations, and referrals for prosecution or regulatory action.
- Collaborate with Compliance, Decision Support, Finance, and Claims teams to refine detection methods and implement recovery strategies.
- Support and mentor investigators by promoting best practices in investigative techniques, documentation, and regulatory interpretation.
- Maintain accurate and timely documentation in accordance with internal procedures and audit standards.
- Represent Program Integrity in audits, regulatory reviews, and cross-departmental initiatives.
- Develop and maintain effective relationships with external stakeholders, including OHA Program Integrity, CMS, MFCUs, and peer plans.
- Contribute to the annual FWA Work Plan and provide insight into emerging fraud trends and investigative priorities.
- Draft and submit regulatory reports related to investigations and recoveries as required.
- Maintain confidentiality and exercise sound judgment in managing sensitive cases.
- Stay informed on current healthcare fraud schemes, enforcement trends, and regulatory changes.
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| CHALLENGES |
- Working with a variety of personalities, maintaining a consistent and fair communication style.
- Thriving in a dynamic and fast-paced environment while meeting the evolving needs of an innovative organization.
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| QUALIFICATIONS |
Minimum Qualifications- AHFI (Accredited Health Care Fraud Investigator) designation required.
- Minimum six (6) years of FWA investigation experience in a health plan, SIU, or government agency.
- Strong knowledge of healthcare billing and coding (ICD, CPT/HCPCS, NDC), claims review, and medical record interpretation.
- Experience conducting interviews, preparing investigative case files, and supporting legal or administrative proceedings.
- Proficient in analyzing large data sets and using analytics tools to identify fraud trends and support case development.
- Effective written and verbal communication skills; able to produce clear, well-documented findings.
- Proven ability to manage complex investigations independently while prioritizing multiple projects
- No suspension/exclusion/debarment from participation in federal health care programs (eg. Medicare/Medicaid)
- Proficient computer skills, including MS Office suite
Preferred Qualifications- Bachelor’s degree in Criminal Justice, Health Administration, Nursing, or related field.
- Additional certifications such as CFE (Certified Fraud Examiner) or CPC/CCS.
- Strong understanding of 42 CFR Part 455, Oregon Administrative Rules (OARs), and Medicaid managed care frameworks.
- Familiarity with Oregon Health Authority (OHA) program integrity protocols and reporting systems.
- Prior experience working in Medicaid managed care.
- Experience considering the impacts of the work on multiple communities, including communities of color, in technical analysis
- Experience working on a diverse team
- Experience working with different communication styles
- Bi-lingual translation or translation capabilities a plus
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| PHYSICAL DEMANDS/WORK CONDITIONS |
- A typical office environment requires standing, sitting, walking, bending, and lifting up to 25 plus pounds.
- Ability to travel and drive to in-person meetings, provider site-visits or legal proceedings as required.
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| EQUAL EMPLOYMENT OPPORTUNITY |
UH is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. UH makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, read through our EEO Policy. |
| JOB DESCRIPTION ACKNOWLEDGEMENT |
| I have reviewed the attached job description as outlined above and understand that I am responsible for all duties as outlined and other tasks as may be assigned. I understand that if I need accommodation to perform the essential functions of my job that I must contact my supervisor or Human Resources as soon as possible to begin an interactive process. |
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| Note: This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship. |
About Umpqua Health
At Umpqua Health, we're more than just a healthcare organization; we're a community-driven Coordinated Care Organization (CCO) committed to improving the health and well-being of individuals and families throughout our region. Umpqua Health serves Douglas County, Oregon, where we prioritize personalized care and innovative solutions to meet the diverse needs of our members. Our comprehensive services include primary care, specialty care, behavioral health services, and care coordination to ensure our members receive holistic, integrated healthcare. Our collaborative approach fosters a supportive environment where every team member plays a vital role in our mission to provide accessible, high-quality healthcare services. From preventative care to managing chronic conditions, we're dedicated to empowering healthier lives and building a stronger, healthier community together. Join us in making a difference at Umpqua Health.
Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.