[Hiring] Provider Fraud Investigator @State of Washington

Role Description

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.

Protect Apple Health from fraud and help make sure public dollars go to the care people need. The Special Investigations Unit (SIU) in HCA’s Division of Audit, Integrity, and Oversight (DAIO) is seeking an Investigator 3 to evaluate allegations of provider fraud in Washington’s Medicaid program. As one of three professional Investigators in the unit, you will:

• Determine whether allegations are credible.
• Build cases from start to finish.
• Work closely with the Attorney General’s Office, managed care organizations, and federal partners to stop fraudulent billing.

Qualifications

• Curious, objective investigator who follows the evidence wherever it leads.
• Stays professional and unbiased under pressure.
• Keeps meticulous records and draws sound conclusions from complex data and documentation.
• Builds strong working relationships with clinical staff, legal partners, and managed care organizations.
• Explains findings clearly, whether in a written report or a case presentation.
• Holds to the highest standards of ethical conduct.

Requirements

• Deep, fluent knowledge of Federal regulations, sub-regulatory guidance, State laws, Agency policies, rules, and managed care contracts.
• Thorough understanding of what constitutes a “credible allegation of fraud" (CAF) and the specific legal thresholds required to refer cases to the Attorney General's Medicaid Fraud Control Division (MFCD/MFAD).
• Demonstrated competency in executing high-stakes administrative actions, such as initiating payment suspension protocols and coordinating joint civil/criminal investigations.
• Demonstrated ability to use independent judgment to formulate, adapt, and execute complex investigative plans of action from scratch.
• Demonstrated understanding of the full lifecycle management of complex cases, from intake (e.g., Hot Tips, referrals) to final resolution and reporting.
• Proficiency in planning and conducting secure, objective onsite investigations of provider facilities or managed care entities (MCEs).
• Advanced competency in querying, analyzing, and mining complex claims data, billing codes, and encounter records to identify anomalous or fraudulent billing patterns.
• Demonstrated ability to objectively review provider billing records, electronic health records (EHR), and MCE financial records.
• Demonstrated ability to look beyond individual fraud cases to identify systemic policy gaps or IT system vulnerabilities that enable fraudulent practices.
• Advanced tactical interviewing skills tailored to diverse audiences.
• A steadfast commitment to professional objectivity, ensuring all findings are strictly anchored in verifiable facts and gathered evidence.
• Competency in managing fraud alerts across multiple networks.
• Excellence in drafting formal investigative reports, legal memorandums, and case presentations suitable for stakeholders, agency leadership, and prosecutors.

Benefits

• 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.