Healthcare Fraud Investigator II – Medicare Part C & D

Remote, U.S.

@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.

The Investigator II is a mid-level professional position that performs evaluations of investigations and makes field level judgments of potential Medicare fraud, waste, and abuse that meet established criteria for referral to law enforcement or administrative action.

Essential Duties and Responsibilities of the Investigator include:

• Utilizing leads provided by the team and referrals from government and private agencies, working with the team to prioritize complaints for investigation, and then investigating, conducting interviews and reviewing information to make potential fraud determination.
• Determining 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.
• Conducting interviews of witnesses, informants, and subject area experts and targets of investigations.
• Identifying, collecting, preserving, analyzing and summarizing evidence, examining records, verifying authenticity of documents, and may provide information to support the preparation of attestations/referrals
• Drafting investigation reports, evaluating investigation reports, and promoting effective and efficient investigations.
• Initiating and maintaining 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.
• Testifying at various legal proceedings as necessary.
• Identifying opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.

Required Experience:

Education and/or Experience

• Required: Bachelor's Degree or four years’ experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions. Equivalent education and experience may be combined.
• Preferred: Experience in Medicare investigations/fraud detection, law enforcement, or prior successful experience with CMS and OIG/FBI or similar agencies. Experience in a federal or state healthcare programs or a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions strongly preferred.

Certificates, Licenses, Registrations 

• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator preferred

Travel Requirements 

• Periodic overnight travel for periods of 1-5 days is required, approximately 3-4 times a year for annual training, and team and industry meetings, which are encouraged.

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.