Intake Investigator I - I-Medic

The position could be based in the Dallas or Easton offices.

Job Summary

Independently performs in-depth evaluation and makes field level judgments 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.

• Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, preparing affidavits or supervising the preparation of affidavits as needed.
• 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.
• Communicates with beneficiaries and providers as needed to resolve beneficiary complaints and assists providers with medical review status.
• Analyzes data for appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria, requesting additional documentation if necessary.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.
• Testifies at various legal proceedings as necessary.
• Refers all potential adverse decisions to the Lead Investigator/Manager.
• Places potential fraudulent providers on prepay review and monitor adjudication of claims.
• 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.
• Drafts and evaluates investigation reports and promote effective and efficient investigations.

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.

Required Experience

Education and/or Experience:

An Associate’s Degree 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 a federal or state healthcare programs
• Experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.
• Experience in health care fraud investigation/detection.

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