[Hiring] Healthcare Fraud Investigator @Orchard

Role Description

We are searching for an Investigator for a Medicaid program who will ensure the integrity and accuracy of claims processes and protocols. This role involves:

• Collecting data for audits/investigations into claims.
• Utilizing a combination of analytical skills and attention to detail.
• Reviewing documentation and interviewing involved parties.
• Communicating with various stakeholders to gather relevant information for successful resolution and closure.
• Identifying opportunities to target fraud, waste, and abuse or discrepancies in claims submissions.
• Adhering to industry regulations and policies for managerial follow-up.
• Analyzing data to effectively assess the validity of claims.
• Providing accurate recommendations to management for claim resolution and closure.
• Documenting and inputting all findings.
• Preparing comprehensive reports that may be used for legal or audit/investigative purposes.

Essential Duties and Responsibilities:

• Conducts routine and impartial audits/investigations from start to closure into customer claims, ensuring accurate and fair assessments of claims validity.
• Provides customer service by addressing inquiries and concerns, and escalates audit/investigation as needed.
• Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements.
• Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process.
• Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims.
• Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards.
• Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
• Assists in providing training and support to other auditors/investigators, contributing to the continuous improvement of investigative processes.

Qualifications

• Minimum Bachelor's Degree
• Minimum of 2-4 years experience in fraud investigation/detection; 5-7 years experience preferred
• Must possess prior experience working with Medicaid.

Requirements

• Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator preferred.
• Prior successful experience with CMS and OIG/FBI or similar agencies preferred.