Supervisor - Audit/Investigation – Healthcare Fraud
Work from Home within the Continental United States

@Orchard LLC is supporting 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. Our client has 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 client operates a foundation providing grant opportunities to those with programs for under-served communities.

Our client is seeking an experienced Supervisor to oversee audits/investigations and audit/investigation workload. In the role you would perform in-depth evaluation and makes field level judgments related to audits/investigations of potential Medicaid Managed Care fraud waste and abuse audits/investigations or cases compliance cases (e.g. Medicare and/or Medicaid) that meet established criteria for referral to the appropriate agency(ies) for administrative action or to law enforcement for criminal action.

Essential Duties and Responsibilities:

• Reviews new audits/investigations and/or incoming leads to determine appropriateness and assigns to auditors/investigators; vets providers as required with appropriate agency(ies) and law enforcement; supervises vetting process. Reviews audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to team.
• Conducts file reviews regularly of audits/investigations to ensure audit/investigation plan is appropriate and the audit/investigation file documents are entered and summarized within the case tracking systems appropriately. Reviews auditor/investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness.
• Supervises and conducts audit/investigation actions such as interviewing, onsite audit/investigation, and/or site verification as needed. Leads audit/investigation projects including developing an audit/investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management.
• Communicates with the Data and Medical Review departments to ensure efficient audits/investigations. Prepares and presents audits/investigations, overpayments, and questions for stakeholder meetings.
• Documents audit/investigation information and file reviews (interviews, events, findings, communications, etc.) into the case tracking systems and updates systems as needed. Determines audit/investigation appropriateness of fraud, waste, and abuse issues in accordance with pre-established criteria. Reviews audit/investigative findings with auditors/investigators and approves course of action. Supervises and prepares team’s audits/investigations for the Major Case Coordination meetings and reviews for quality assurance.
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting audit/investigation findings for their consideration to further audit/investigate, prosecute, or seek other appropriate regulatory or administrative remedies. Supervises administrative remedies in accordance with major case coordination direction (e.g. payment suspensions, revocations, provider education) and reviews for quality assurance. Reviews and approves closing summary of audit/investigation.
• Collects information and documentation as requested by internal and external stakeholders (e.g. CMS, law enforcement, FOIA requests) and submits, as required.
• Collaborates with other program integrity contractors, as needed.
• Testifies at various legal or administrative proceedings, as necessary.
• Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.

Level of Supervision Received:
Drives work independently and escalates questions and issues, as needed

Your background will include.

·        Minimum Bachelor's Degree required 

·        5 - 7 years of experience required; 8 - 11 years preferred

·        Medicaid Managed Care experience preferred

Certificates, Licenses, Registrations

• Current, active and non-restricted RN licensure required.

If you match the requirements for this opportunity and believe you have the experience and talent to succeed in the role, we need to hear from you!

Established in 2010, @Orchard LLC, also known as, Talent 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.