Healthcare Fraud Investigator I - Entry Level Salaried

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. 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 Salt Lake City or Atlanta. 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.

• 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.
• Has the responsibility and authority to perform their job and provide customer satisfaction
• 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.
• Testifies at various legal proceedings as necessary.
• Identifies opportunities to improve processes and procedures.
• 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.
• 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.

Required Skills

• Ability to effectively resolve complex issues.
• Certificates, Licenses, Registrations: Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator preferred
• Other Skills and Abilities:
• 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.
• 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.
• Mathematical Skills: Ability to apply basic mathematical functions.
• Ability to communicate effectively with all members of the team to which he/she is assigned.
• Ability to work independently with minimal supervision.
• Ability to mentor other associates.
• 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 grasp and adapt to changes in procedure and process.

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.

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.