Healthcare Fraud Investigator II - Medicaid

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.

Are you skilled in reviewing Medicaid claims and source records?  Do you have a track record of exceeding expectations, meeting deadlines and handling multiple assignments?  If that sounds like you, Qlarant has the perfect opportunity! We have an immediate opening for a Healthcare Fraud Investigator II on our UPIC SW Medicaid investigations team. This position could be based in our Dallas, TX office or home-based in most states in the continental US. Qlarant offers an excellent benefits package that includes healthcare, two retirement plans and a generous leave program. 

As a Healthcare Fraud Investigator II working on our Unified Program Integrity Contractor (UPIC) team for the Southwest Jurisdiction, you can contribute to our efforts to make a positive difference in the future of the Medicare and Medicaid programs.  Our UPIC Southwest team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 7 states.

This is a mid-level professional position that performs evaluations of investigations and makes field level judgments of potential Medicaid and Medicare fraud, waste, and abuse that meet established criteria for referral to law enforcement or administrative action.

Essential Duties and Responsibilities:

• 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.

·         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

·         Additional required skills include:

·         Report writing and documentation

·         Federal and State Policy research

·         Reviewing Medicaid claims and source records

·         Proficiency in Microsoft Excel and Word

·         Attention to detail

·         Bachelor's Degree and two years’ experience in investigations/fraud detection or healthcare programs required.

·         Experience reviewing Medicaid claims or exposure to Medicaid (administrative, investigative, data, or otherwise) is 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.