Heath Fraud Quality Reviewer/Investigator
Orchard LLC

Heath Fraud Quality Reviewer/Investigator (Project Manager I)
Remote U.S.

@Orchard LLC is supporting 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. Our client has 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 client operates a foundation providing grant opportunities to those with programs for under-served communities.

Our Client's Investigative MEDIC team is seeking a Heath Fraud Quality Reviewer (Project Manager I) with significant experience in health fraud investigation to include an in-depth understanding of investigative processes and detailed documentation of investigative steps following all CMS program requirements. This individual will provide an advanced level of project management to all members of the contract team. The Investigative MEDIC team has a nationwide contract with CMS to detect and prevent Medicare Part C and Part D fraud, waste, and abuse. This is an opportunity to make a positive difference in the future of the nation's healthcare programs. Plans, manages, and coordinates activities of designated project(s) to ensure that goals or objectives of project are accomplished within prescribed time frame.

Essential Duties and Responsibilities include the following.

Approximately 40% of duties will consist of the following:

• Pulls and/or reviews samples from UCM for RFI/RFA/Leads/Investigators (monthly) to review documentation.
• Pulls samples of complaints from MCMS to review documentation.
• Reviews all records to determine if the correct investigative steps were taken.
• Determines if all metrics established by CMS are being met.
• Provides reports to the PI Manager, Deputy Director and Program Director regarding findings and recommendations.
• Develops training as needed.
• Works with the development team to determine if any efficiencies can be made with internal case tracking to ensure better quality.
• Works with the CMS UCM team to provide feedback on the upcoming rebuilding of the case tracking system to ensure quality.

Approximately 40% of duties will consist of the following:

• Mentors investigators by providing support to mentee during onboarding: (e.g., how to navigate SilkRoad Onboarding & Learning and Quality Management System (QMS) portal; Where to find forms & documents and who to reach out to).
• Demonstrate appropriate job-related work examples (i.e., on-the-job training, e.g., including but not limited to providing instruction on using various Systems to do work, using templates and submitting forms, how to develop and document investigations, how to conduct interviews and identify administrative actions).
• Review mentees work submission before it is submitted to Lead.
• Ensure mentee is invited to and attending appropriate meetings.
• Provide general support to mentee, answer questions & troubleshoot, but escalate issues to Lead as needed.
• Work with Lead to provide good instructions on case management and meeting timelines.
• Reinforce what Lead is teaching and keep Lead informed on mentees' progress, issues, or concerns.

Approximately 10% of duties will consist of the following:

• Develop reactive investigations and initiated proactive projects and data analyses.
• Adhere to CMS requirements as well as I-MEDIC internal requirements.
• Analyze data for inappropriate prescribing patterns and/or coding issues within the Medicare Part C and D data.
• Conduct interviews (e.g., complainants, prescribers and beneficiaries).
• Maintained communication with plan sponsors, pharmacy benefit managers and law enforcement to assist with investigations.
• Document all investigative steps in Unified Case Management (UCM) system in a timely manner.
• Submitted written referrals of significant findings to outside agencies and customers.

Supervisory Responsibilities

The position manages the activities of a project/s and handles day-to-day affairs of a team, but is not responsible for the long-term traditional functions of a direct manager, as this is an individual contributor position.

Required Experience:
Education and/or Experience:

• Bachelor's degree in a relevant field preferred, extensive experience in the field to include at least two years' experience in fraud investigation project management and/or quality review of investigations; or equivalent combination of education and experience.
• At least two years of health fraud investigations experience that required documentation of findings and an understanding of request for information processes and SOW requirements.
• I-MEDIC and/or UPIC experience strongly preferred.

Certificates, Licenses, Registrations:

• Active CFE, AHFI, PMP, CPHQ, CPHM, and or CCM is desirable

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 www.atOrchard.com.

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