Healthcare Fraud Investigator Lead - 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. 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.

Qlarant has an immediate opening for a Healthcare Fraud Lead Investigator - Medicare to provide supervision and mentoring to a team of Investigators.  In addition to your exceptional healthcare fraud investigation knowledge and experience, well qualified candidates will possess prior supervisory and leadership experience.  The position may be worked remotely.

Job Summary: This position oversees investigations and investigation workload. Independently performs in-depth evaluation and makes field level judgments related to investigations of potential Medicare fraud waste and abuse investigations or cases compliance cases 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:

• Supervises intake investigators and/or investigators and assigns work; regularly reviews team’s leads in screening and/or investigations and actions for quality and appropriateness; monitors workload distribution and timeliness
• Reviews new investigations and/or incoming leads to determine appropriateness and assigns to investigators; vets providers as required with CMS, law enforcement and supervises vetting process
• Reviews investigation plans and priority to ensure appropriateness and quality for the specific functions/workload assigned to their team
• Conducts file reviews regularly of investigations to ensure investigation plan is appropriate and the investigation file documents are entered and summarized within the case tracking systems appropriately
• Reviews investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness
• Supervises and conducts investigation actions such as interviewing, onsite investigation, site verification as needed
• Trains new investigators
• Leads investigation projects including developing an investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management
• Communicates with the Data and Medical Review departments to ensure efficient investigations
• Prepares and presents investigations, overpayments, and questions for the weekly CMS meetings
• Determines investigation appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria
• Reviews investigative findings with investigators and approves course of action
• Supervises and prepares team’s investigations for the Major Case Coordination meetings and reviews for quality assurance
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies
• Collaborates with other program integrity contractors as needed
• Testifies at various legal proceedings as necessary

Supervisory Responsibilities                                                    

Supervises staff in the operational area.  Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

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.

Judgment - Supports and explains reasoning for decisions.

• Bachelor's Degree or four years’ experience in a field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions or equivalent combination of education and experience.
• Three years' experience in healthcare programs or fraud investigation/detection 
• Extensive experience in healthcare fraud investigation/detection required.
• Must possess prior experience in federal or state healthcare programs or a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.
• Prior successful experience with CMS and OIG/FBI or similar agencies strongly preferred.

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