Healthcare Fraud Investigator Lead – Medicare/Medicaid – Remote or Office Based Job at Qlarant

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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.

Qlarant has an immediate opening for an Investigator Lead to provide supervision and mentoring to a team of healthcare fraud Investigators.  In addition to your exceptional healthcare fraud investigation knowledge and experience, well qualified candidates will possess prior supervisory and leadership experience.  This position can be home-based in most areas of the U.S. or based in our Los Alamitos, CA office.

As an Investigator Lead working on our Unified Program Integrity Contractor (UPIC) team for the Western Jurisdiction, you can contribute to our efforts to make a positive difference in the future of the Medicare and Medicaid programs.  Our UPIC West team identifies and investigates fraud, waste and abuse in the Medicare and Medicaid programs covering 13 states and 3 territories. 

The Investigator Lead oversees investigations and investigation workload. Independently performs in-depth evaluation and makes field level judgments related to investigations of potential Medicare fraud waste and abuse investigations or cases compliance cases 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.

  • Supervises intake investigators and/or investigators and assigns work; regularly reviews team’s leads in screening and/or investigations and actions for quality and appropriateness; monitors workload distribution and timeliness
  • Reviews new investigations and/or incoming leads to determine appropriateness and assigns to investigators; vets providers as required with CMS, law enforcement and supervises vetting process
  • Reviews investigation plans and priority to ensure appropriateness and quality for the specific functions/workload assigned to their team
  • Conducts file reviews regularly of investigations to ensure investigation plan is appropriate and the investigation file documents are entered and summarized within the case tracking systems appropriately
  • Reviews investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness
  • Supervises and conducts investigation actions such as interviewing, onsite investigation, site verification as needed
  • Trains new investigators
  • Leads investigation projects including developing an investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management
  • Utilizes government systems to obtain and analyze provider and beneficiary information
  • Queries Business Objects to run data reports for provider billing information and to analyze for fraud indicators
  • Utilizes CLEAR system to obtain provider information and develop investigation
  • Communicates with the Data and Medical Review departments to ensure efficient investigations
  • Prepares and presents investigations, overpayments, and questions for the weekly CMS meetings
  • Documents investigation information and file reviews (interviews, events, findings, communications, etc.) into the case tracking systems and updates systems as needed
  • Determines investigation appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria
  • Reviews investigative findings with investigators and approves course of action
  • Based on contract requirements, may refer potential adverse decisions to the Manager, Medical Director, or designee
  • Supervises and prepares team’s 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 investigation findings for their consideration to further 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 investigation
  • Collect information and documentation as requested by internal and external stakeholders (e.g. CMS, law enforcement, FOIA requests) and submit as required
  • Collaborates with other program integrity contractors as needed
  • Testifies at various legal proceedings as necessary
  • Identifies opportunities to improve processes and procedures
  • Assists Program Integrity Manager and VP of Operations with information and reporting for contract deliverables

Supervisory Responsibilities                                                    

Supervises staff in the operational area.  Carries out supervisory responsibilities in accordance with the organization’s policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Required Skills

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.
  • Written Communication – Writes clearly and informatively; Able to read and interpret written information.
  • Judgment – Supports and explains reasoning for decisions.

Required Experience


  • A Bachelor’s Degree or four years’ experience in a field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions or equivalent combination of education and experience
  • Three years’ experience fraud investigation/detection (preferred) or in healthcare programs.


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

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