Qlarant, Inc. 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.
Seeking a career in Healthcare fraud investigation? Qlarant has the perfect opportunity! The Intake Investigator is an entry level hourly position that serves as a member of our Dallas-based Unified Program Integrity Contract (UPIC) investigative team for the Southwest jurisdiction. New grads with a degree in Criminal Justice or a related field and strong analytical skills are encouraged to apply. This position is office-based in our Dallas office. The selected candidate must reside within a reasonable commuting distance of our office.
JOB SUMMARY:
Assists and supports in-depth investigations related to complaints and proactive leads of potential Medicare fraud investigations 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.
- Enters investigative information into the case tracking systems and will meet with Lead Investigators to assign investigations to the Investigative team.
- Works with the team to prioritize complaints for investigations.
- Places potential fraudulent providers on prepay review and monitor adjudication of claims.
- Analyzes data for appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria, requesting additional documentation if necessary.
- Refers all potential adverse decisions to the Lead Investigator/Manager.
- Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, preparing affidavits or supervising the preparation of affidavits as needed.
- Drafts and evaluates investigation reports and promote effective and efficient investigations.
- Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
- Testifies at various legal proceedings as necessary.
- Communicates with beneficiaries and providers as needed to resolve beneficiary complaints and assists providers with medical review status.
- Identifies opportunities to improve processes and procedures.
- Has the responsibility and authority to perform their job and provide customer satisfaction.
Required Skills
TO PERFORM THE JOB SUCCESSFULLY, AN INDIVIDUAL SHOULD DEMONSTRATE THE FOLLOWING COMPETENCIES:
- 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.
Required Experience
EDUCATION AND/OR EXPERIENCE:
An Associate’s Degree (Bachelor's preferred) or one or more of the following:
- Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification
- Experience in health care fraud investigation/detection.
- Experience in a federal or state healthcare programs
- Experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.