Sr. Program Integrity Investigator

Position Summary:
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 Duties and 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.

• 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.

• 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.

• Hybrid or remote eligible, depending on location and organizational need.
• Occasional in-person meetings, provider site visits, or legal proceeding attendance may be required.

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.