Healthcare Fraud Investigator I - Remote or Office Based

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. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. 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.

Best People, Best Solutions, Best Results

Job Summary:

Entry level professional performs evaluations of investigations and makes field level judgments of potential Medicaid and/or Medicare fraud, waste and abuse that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action.

Essential Duties and Responsibilities include the following. Other duties may be assigned

• 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, examining records, verifying authenticity of documents, may provide information to support the preparation of attestations/referrals or supervising the preparation of attestations/referrals as needed.
• 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.

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

• 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.

Education and/or Experience

• A Bachelor's Degree or at least 4 years of experience in a federal or state healthcare programs or a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.
• Experience in Medicare/Medicaid fraud investigation/detection required.
• 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 preferred.

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