Healthcare Fraud Investigator-Medicare/Medicaid
Orchard LLC

Job Info

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Healthcare Fraud Investigator - Medicare/Medicaid
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 has an immediate opening for an Entry-level Investigator professional to perform evaluations of investigations and make field-level judgments of potential Medicaid and/or Medicare fraud, waste, and abuse 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.

• 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.
• Based on contract requirements, may refer potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee.
• Conducts interviews of witnesses, informants, and subject area experts and targets of investigations.
• Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, may provide information to support the preparation of attestations/referrals or supervising the preparation of attestations/referrals as needed.
• Drafts investigation reports, evaluates investigation reports, and promotes effective and efficient investigations.
  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.
• Testifies at various legal proceedings as necessary.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction..

Your background will include:

• A Bachelor's Degree or at least 4 years of experience in a federal or state healthcare program or a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.
• Experience in Medicare/Medicaid fraud investigation/detection is required.
• Prior successful experience with CMS and OIG/FBI or similar agencies preferred.
• Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification is 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.

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