Medicaid Investigator II

Qlarant 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 have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Best People, Best Solutions, Best Results

Job Summary:

The Investigator II is a mid-level professional position that performs evaluations of investigations and makes field level judgments of potential Medicare and/or Medicaid fraud, waste, and abuse that meet established criteria for referral to law enforcement or administrative 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, examines records, verifies authenticity of documents, and may provide information to support the preparation of attestations/referrals
• 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.

Supervisory Responsibilities: This job has no supervisory responsibilities.

To perform the job successfully, an individual should demonstrate the following competencies:

• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.
• Problem Solving - Gathers and analyses information skillfully; Identifies and resolves problems.
• Communication - Writes clearly and informatively; Able to read and interpret written information.
• Judgment - Supports and explains reasoning for decisions.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.