Healthcare Fraud Investigator II - Medicaid
Orchard LLC

Job Info

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Healthcare Fraud Investigator II - Medicaid
Remote U.S.

@Orchard LLC is retained by 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. Our Client 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. Our client offers an excellent benefits package that includes healthcare, two retirement plans and a generous leave program.

Preference will be given to candidates residing in the following Western Jurisdiction states: AZ, CA, OR, WA, ID, NV, UT, SD, or ND. As a Healthcare Fraud Investigator II working on this team for the Western Jurisdiction, you can contribute to our efforts to make a positive difference in the future of the Medicare and Medicaid programs. This team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 13 states and 3 territories. 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:

• 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.

Education and /or Skills and Experience Required:

• Bachelor's Degree and two years' related investigations/fraud detection experience with Medicaid requried.
• Experience with Medicaid investigations experience / prior UPIC experience / prior experience with Medicaid health plans (MCOs) is 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 or successful completion of a law enforcement academy preferred.
• Strong writing skills for report writing and documentation,
• Experience with Federal and State Policy research preferred.
• Proficiency in Microsoft Excel and Word needed.
• Strong attention to detail.

Established in 2010, @Orchard has an exceptional reputation, providing staffing solutions to time-sensitive, talent scarcity issues to deliver better talent management ROI. Our specialty lies in the critical area of program talent acquisition and resource management, not in one narrow skillset, but across many areas of technical and functional delivery. To learn more about our other exciting opportunities, visit our Jobs Page at www.atorchard.com.

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