Entry Level Health Fraud Investigator - Perfect For New Grads!
Qlarant, Inc., 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're a national leader in fighting fraud, waste and abuse for large organizations across the country.
Are you a recent grad with a degree in Criminal Justice, Criminology, or a related field of study? Qlarant's Intake Investigator position is the perfect opportunity for you to begin your career in healthcare fraud, waste and abuse investigation! As a member of our Cerritos, CA based Unified Program Integrity Contractors (UPIC) team, you'll receive extensive training and mentoring in a job where you can make a positive difference in the future of the nation's Medicare and Medicaid programs. Our UPIC West team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 16 Western states and territories.
We're seeking high performing candidates with a track record of exceeding expectations. Candidates possessing strong analytical, communication and MS Office skills are a great fit for this position. Strong attention to detail and an organized approach to your work are also key traits for success in this position. The selected candidates will work in the Cerritos, CA office located near the Sheraton Cerritos. Qlarant employees enjoy a collaborative work environment and a very competitive compensation and benefits program.
As an Intake Investigator, you'll assist our Health Fraud Investigators in performing in-depth evaluations and making field level judgments related to complaints and proactive leads of potential Medicare and Medicaid fraud investigations that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action.
Job Summary: Independently performs in-depth evaluation and makes field level judgments related to complaints and proactive leads of potential Medicare fraud investigations 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.
- Enters investigative information into the case tracking systems and will meet with Lead Investigators to assign investigations to the Investigative team.
- Works with the team to prioritize complaints for investigations.
- Places potential fraudulent providers on prepay review and monitor adjudication of claims.
- Analyzes data for appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria, requesting additional documentation if necessary.
- Refers all potential adverse decisions to the Lead Investigator/Manager.
- Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, preparing affidavits or supervising the preparation of affidavits as needed.
- Drafts and evaluates investigation reports and promote effective and efficient investigations.
- Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
- Testifies at various legal proceedings as necessary.
- Communicates with beneficiaries and providers as needed to resolve beneficiary complaints and assists providers with medical review status.
- 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 utilize Microsoft Word, Excel and Outlook at an intermediate level.
- An Associate’s Degree or higher is required. A degree in Criminal Justice, Criminology, Sociology, Psychology or a related field is strongly preferred.
- One or one or more of the following may be substituted for the degree for an experienced candidate:
- Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification
- Experience in health care fraud investigation/detection.
- Experience in a federal or state healthcare programs
- Experience in a related field such as medical claims review that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.
- Intermediate level skill in the use of Microsoft Office to include Word, Excel and Outlook.
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.