Job Description

Job Description

Job Description

Healthcare Fraud Investigator I – Medicaid

Dallas, TX (hybrid) OR Remote U.S.

@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 country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Serves as an entry level professional who develops baseline plans for ensuring the integrity and accuracy of claims processes and protocols. Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Adheres to industry regulations and company policies for managerial follow-up. Analyzes data in order to effectively assess the validity of claims. Provides accurate recommendations to management for claim resolution and closure. Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes.

Essential Duties and Responsibilities :

• Conducts routine and impartial audits/investigations 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.
• Ensures that all audit and investigative documents and records are processed into the database in a timely and accurate manner.
• Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
• Supports management in regular audit and investigation proceedings, ensuring full compliance with all applicable regional and federal standards, regulations, and protocols.

Education and /or Skills and Experience Required:

• Minimum Bachelor's Degree
• Prior experience in federal or state healthcare programs or a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions related to fraud, waste and abuse.

Preferred Skills/Experience:

• Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator
• Prior successful experience with CMS and OIG/FBI or similar agencies
• Medicaid investigation experience strongly preferred
• Claims Analysis or Policy Research experience 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!

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 .

Job Tags

Remote work,

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