Healthcare Fraud Investigator Lead-Medicare
- Job Title
- Healthcare Fraud Investigator Lead-Medicare
- Job ID
- 27741902
- Work From Home
- Yes
- Work Remote
- Yes
- Location
- Work From Home Remote
- Other Location
- Description
-
Healthcare Fraud Investigator Lead – Medicare
@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.
Work from Home, within the Continental United States
Our client has an immediate opening for an Investigator Lead to provide supervision and mentoring to a team of healthcare fraud Investigators. In addition to your exceptional healthcare fraud investigation knowledge and experience, well-qualified candidates will possess prior supervisory and leadership experience.
As an Investigator Lead, you can contribute to making a positive difference in the future of the Medicare program. Our client’s team identifies and investigates fraud, waste, and abuse in the Medicare program covering 13 states and 3 territories, within the Western United States.This position oversees investigations and investigation workload. Independently performs in-depth evaluation and makes field-level judgments related to investigations of potential Medicare fraud waste and abuse investigations or cases compliance cases that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action. In addition to your exceptional healthcare fraud investigation knowledge and experience, well-qualified candidates will possess prior supervisory and leadership experience.
Essential Duties and Responsibilities.- Supervise intake investigators and assign work; regularly review leads for quality and appropriateness; monitor workload distribution and timelines.
- Review new investigations and/or incoming leads to determine appropriateness and assign to investigators; vet providers as required with CMS, and law enforcement, and supervise the vetting process.
- Review investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to their team.
- Conduct file reviews regularly of investigations to ensure the investigation plan is appropriate and the investigation file documents are entered and summarized within the case tracking systems appropriately.
- Review investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness.
- Supervise and conduct investigation actions such as interviewing, onsite investigation, and site verification as needed.
- Train new investigators.
- Lead investigation projects including developing an investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management.
- Utilize government systems to obtain and analyze provider and beneficiary information.
- Query Business Objects to run data reports for provider billing information and to analyze for fraud indicators.
- Communicate with the Data and Medical Review departments to ensure efficient investigations.
- Document investigation information and file reviews (interviews, events, findings, communications, etc.) into the case tracking systems and updates systems as needed.
- Review investigative findings with investigators and approves the course of action.
- Based on contract requirements, may refer potential adverse decisions to the Manager, Medical Director, or designee.
- Initiate and maintain communications with law enforcement and appropriate regulatory agencies including assisting with presenting investigation findings for further investigation.
- Testify at various legal proceedings as necessary.
- Identify opportunities to improve processes and procedures.
- Assist the Program Integrity Manager and VP of Operations with information and reporting for contract deliverables.
Your background will include:- A bachelor’s degree or four years of experience in a field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions or an equivalent combination of education and experience.
- Three years of experience in healthcare programs or fraud investigation/detection.
- Direct knowledge of the Medicare program, how it works, what actions can be taken against providers if necessary.
- Experience working for a Medicare Administrative Contractor or in Medicare billing and review with a healthcare provider preferred.
- Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator is preferred but not required.
- Prior successful experience with CMS and OIG/FBI or similar agencies.
- Prior supervisory experience is strongly preferred.
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.
