Intake Investigator Lead Healthcare Fraud

Intake Investigator Lead - Healthcare Fraud
Los Alamitos CA (hybrid)

@Orchard LLC is retained by 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. Our Client is also a national leader in fighting fraud waste and abuse for large organizations across the addition our Foundation provides grant opportunities to those with programs for under-served communities.

Our client has an immediate opening for an experienced Supervisor for their Audit/Investigation Intake team to oversee critical operations related to Medicare and Medicaid fraud waste and abuse detection. As the Supervisor of Audit/Investigation you will play a pivotal role in maintaining the integrity of healthcare programs by leading a team of auditors and investigators in identifying potential fraud waste and abuse. Your responsibilities will encompass comprehensive oversight of audit and investigation processes ensuring adherence to established protocols and quality standards.

Essential Duties and Responsibilities:

• You will be responsible for reviewing new audits/investigations and incoming leads determining their appropriateness and assigning them to team members. A critical aspect of your role involves vetting providers with appropriate agencies and law enforcement as well as supervising the entire vetting process. Youll review audit/investigation plans and priorities to ensure they align with the specific functions and workload assigned to your team.
• Regular file reviews will be conducted under your supervision to verify that audit/investigation plans are appropriate and that all documentation is properly entered and summarized within case tracking systems. Youll also review and approve information requests data reports and correspondence to maintain quality and appropriateness.
• Your hands-on approach will include supervising and conducting audit/investigation actions such as interviews onsite audits/investigations and site verifications as needed. Youll lead audit/investigation projects develop strategies conduct stakeholder meetings review project actions for quality and document findings in management reports.
• Effective communication with the Data and Medical Review departments will be essential to ensure efficient audits/investigations. Youll prepare and present audits/investigations overpayments and questions for stakeholder meetings while documenting all relevant information in case tracking systems.
• A key responsibility will be determining the appropriateness of fraud waste and abuse issues according to pre-established criteria. Youll review investigative findings with your team and approve courses of action while supervising and preparing team audits/investigations for Major Case Coordination meetings and quality assurance reviews.
• Youll initiate and maintain communications with law enforcement and appropriate regulatory agencies presenting or assisting with presenting audit/investigation findings for their consideration. Supervision of administrative remedies in accordance with major case coordination direction will fall under your purview as will reviewing and approving closing summaries of audits/investigations.
• The role requires collection and submission of information and documentation as requested by internal and external stakeholders collaboration with other program integrity contractors and potentially testifying at various legal or administrative proceedings.
• As a manager youll be responsible for team performance through regular feedback and formal performance reviews ensuring exceptional service delivery engagement motivation and team development.
• Reviews new audits/investigations and/or incoming leads to determine appropriateness and assigns to auditors/investigators; vets providers as required with appropriate agency(ies) and law enforcement; supervises vetting process. Reviews audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to team.
• Conducts file reviews regularly of audits/investigations to ensure audit/investigation plan is appropriate and the audit/investigation file documents are entered and summarized within the case tracking systems appropriately. Reviews auditor/investigator requests for information data reports and correspondence to ensure quality and appropriateness.
• Supervises and conducts audit/investigation actions such as interviewing onsite audit/investigation and/or site verification as needed. Leads audit/investigation projects including developing an audit/investigation strategy conducting meetings with stakeholders reviewing project actions for quality and documenting findings in reports for management.
• Communicates with the Data and Medical Review departments to ensure efficient audits/investigations. Prepares and presents audits/investigations overpayments and questions for stakeholder meetings.
• Documents audit/investigation information and file reviews (interviews events findings communications etc.) into the case tracking systems and updates systems as needed. Determines audit/investigation appropriateness of fraud waste and abuse issues in accordance with pre-established criteria. Reviews audit/investigative findings with auditors/investigators and approves course of action. Supervises and prepares teams audits/investigations for the Major Case Coordination meetings and reviews for quality assurance.
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting audit/investigation findings for their consideration to further audit/investigate prosecute or seek other appropriate regulatory or administrative remedies. Supervises administrative remedies in accordance with major case coordination direction (e.g. payment suspensions revocations provider education) and reviews for quality assurance. Reviews and approves closing summary of audit/investigation.
• Collects information and documentation as requested by internal and external stakeholders (e.g. CMS law enforcement FOIA requests) and submits as required.
• Collaborates with other program integrity contractors as needed.
• Testifies at various legal or administrative proceedings as necessary.
• Manages team performance through regular timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement motivation and team development.

Education (education can be substituted for experience):

• Minimum Bachelors Degree
• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred

Work Experience (experience can be substituted for education)

• Minimum of 5-7 years experience
• Minimum of 8-11 years experience preferred
• Experience supervising audit or investigation teams preferred
• Background in Medicare/Medicaid program integrity preferred
• Experience collaborating with law enforcement agencies preferred
• History of managing complex investigations preferred
• Experience in preparing and presenting findings to stakeholders preferred
• Background in healthcare regulatory compliance preferred
• Experience with administrative remedies in healthcare fraud cases preferred
• Demonstrated ability to manage team performance preferred
• Experience with case tracking systems and documentation preferred
• Background in conducting interviews and site verifications preferred
• Experience in quality assurance processes preferred

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!

The compensation for this position is in the range of $81500 to $86500 commensurate with experience and qualifications.

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 .