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Health Fraud Investigator - Cerritos
Best People. Best Solutions. Best Results.®
Qlarant, Inc., formerly known as Health Integrity, is 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. We're a national leader in fighting fraud, waste and abuse for large organizations across the country.
Health Fraud Investigator
Are you an experienced health care fraud investigator with a track record of successful outcomes and exceeding expectations? As a Health Care Fraud Investigator working on our Unified Program Integrity Contractors (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.
Please Note: This position is based in our Cerritos, CA office. Candidates desiring to be home-based outside the UPIC Western jurisdiction will not be considered.
Our investigators independently perform in-depth evaluation and make field level judgments related to investigations of potential Medicare and Medicaid fraud, waste and abuse investigations or cases 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
- 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.
- 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.
- Ability to mentor other associates.
A Bachelor'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
- successful completion of a law enforcement academy
- experience in health care fraud investigation/detection.
Must possess experience in a federal or state healthcare programs or a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions. Prior successful experience with CMS and OIG/FBI or similar agencies preferred.
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.