Entry Level Healthcare Fraud Investigator

Delmarva Foundation Dallas , TX 75201

Posted 2 weeks ago

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.

Seeking a career in Healthcare fraud investigation? Want to make a difference in the future of the Medicare and Medicaid programs? Qlarant has the perfect opportunity! The Intake Investigator is an hourly position that serves as a member of our Dallas-based Unified Program Integrity Contract (UPIC) investigative team for the Southwest jurisdiction. Strong analytical skills are a must! This position is office-based in our Dallas office. The selected candidate must reside within a reasonable commuting distance of our office. Please note: This is an hourly technical support position with a starting wage commensurate with the required qualifications. It is not a professional level position.

Job Summary:

Assists and supports in-depth investigations 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.

Required Skills

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 Office (Word, Excel, Outlook) at an Intermediate level.

Required Experience

Education and/or Experience:

An Associate's Degree (Bachelor's preferred) or one or more of the following:

  • 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 that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.

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

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Entry Level Healthcare Fraud Investigator

Delmarva Foundation