Healthcare Fraud investigator II – Medicare

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

We have an immediate opening for an experienced healthcare fraud investigator (Investigator II) on our UPIC West Medicare investigations team. This position could be based in our Los Alamitos, CA office or home based in most states for a well-qualified candidate. Our Unified Program Integrity Contractor (UPIC) West team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 16 states and territories in the West jurisdiction.

The salary range varies by geographic region based on cost of labor. For example, the hiring range for a well-qualified candidate in Los Angeles or Chicago would be up to $83,800 and up to $76,200 for Atlanta, Baltimore, Dallas, Phoenix or Salt Lake City. We offer an excellent benefits package that includes healthcare, two retirement plans and a generous leave program.

Responsibilities

The Investigator II is a mid-level professional position that performs evaluations of investigations and makes field level judgments of potential Medicare and/or Medicaid fraud, waste, and abuse that meet established criteria for referral to law enforcement or administrative action. Essential duties and responsibilities include but are not limited to:

• Utilizes leads provided by the team and referrals from government and private agencies, works with the team to prioritize complaints for investigation, and then investigates, conducts interviews and reviews information to make potential fraud determination.
• Determines investigation or case appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria.
• Based on contract requirements, may refer potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee.
• Conducts interviews of witnesses, informants, and subject area experts and targets of investigations.
• Identifies, collects, preserves, analyzes and summarizes evidence, examines records, verifies authenticity of documents, and may provide information to support the preparation of attestations/referrals
• Drafts investigation reports, evaluates investigation reports, and promotes effective and efficient investigations.
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
• Testifies at various legal proceedings as necessary.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.

Supervisory Responsibilities: This job has no supervisory responsibilities.

Required Skills

To perform the job successfully, an individual should demonstrate the following competencies:

• Analytical – Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.
• Problem Solving- Gathers and analyses information skillfully; Identifies and resolves problems.
• Written Communication- Writes clearly and informatively; Able to read and interpret written information. Please Note: A writing assignment may be requested during the interview process.
• Judgment- Supports and explains reasoning for decisions.
• Reasoning Ability – Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Computer Skills – To perform this job successfully, an individual must have knowledge of office software and the internet to meet contract deliverables. Utilizes required data entry and reporting systems, including advanced features.
• Certificates, Licenses, Registrations – Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator preferred

Other Skills And Abilities

• Ability to work independently with minimal supervision.
• Ability to communicate effectively with all members of the team to which he/she is assigned.
• Ability to grasp and adapt to changes in procedure and process.
• Ability to effectively resolve complex issues.
• Ability to mentor other associates.

Required Experience

• Bachelor’s Degree and two years’ experience in investigations/fraud detection or related healthcare programs. Equivalent education and experience may be combined.
• Experience in healthcare fraud investigation/detection involving Medicare strongly preferred.
• Prior successful experience with CMS and OIG/FBI or similar agencies preferred
• Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification or successful completion of a law enforcement academy preferred.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.