Entry Level Medicaid Fraud Investigator - Remote Or Office Based

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient deliver! y 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.

Looking for a career in healthcare fraud investigation? Qlarant has an immediate opening for an Healthcare Fraud Investigator I to work on our Medicaid Investigations team. This position could be based in our Los Alamitos, CA office or home based in most states. Please note: This is not a senior level position and the salary is commensurate with the requirements stated below. The salary range varies by geographic region based on cost of labor. For example, the hiring range for a well qualified candidate in Los Angeles or Chicago would be up to $72,800 and up to $66,200 for Atlanta, Dallas, Phoenix or Salt Lake City. We offer an excellent benefits package that includes healthcare, two retirement plans and a generous leave program.

As a Healthcare Fraud Investigator working on our Unified Program Integrity Contractor (UPIC) 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. Our UPIC West team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 13 states and 3 territories.

The Investigator I is an entry level professional that performs evaluations of investigations and makes field level judgments of potential Medicaid and/or Medicare fraud, waste and abuse that meet established criteria for referral to law enforcement or administrative action. Essential duties and responsibilities include the following. Other duties may be assigned.

• Identifies opportunities to improve processes and procedures.
• Testifies at various legal proceedings as necessary.
• 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.
• Conducts interviews of witnesses, informants, and subject area experts and targets of investigations.
• Has the responsibility and authority to perform their job and provide customer satisfaction
• 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.
• Based on contract requirements, may refer potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee.
• 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.
• Determines investigation or case appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria.

Required Skills

• Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
• Ability to mentor other associates.
• Computer Skills: To perform this job successfully, an individual must have knowledge of office software and the internet to meet contract deliverables. Utilizes required data entry and reporting systems, including advanced features.
• Ability to work independently with minimal supervision.
• Ability to effectively resolve complex issues.
• Ability to grasp and adapt to changes in procedure and process.
• Mathematical Skills: Ability to apply basic mathematical functions.
• Certificates, Licenses, Registrations: Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator preferred
• Language Skills: Ability to read, analyze, and interpret technical procedures, review documents, or contract regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
• Ability to communicate effectively with all members of the team to which he/she is assigned.
• Other Skills and Abilities:

Required Experience

Eduction and Experience

• Experience in investigations/fraud detection, law enforcement, or federal/state healthcare programs preferred.
• Bachelor's Degree or four years’ experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions is required. Equivalent education and experience may be combined.
• Medicaid experience preferred.

Certificates, Licenses, Registrations: Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator preferred

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