Job Description

Job Description

Job Description

Healthcare Fraud Investigator – Medicare

Dallas, TX (OR) Houston, TX – preferred

Will consider work from Home in TX, LA, MS, NM, CO, AR or OK

@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.

We are searching for an Investigator for a Medicare program who will monitor the processing and reconciliation of incoming electronic medical records, importing of prepay claims and records, and generating other operation reports related to process of prepay claims. This role also supports research of prepay and post-pay record questions as well as research and return of misdirected documents.

• Monitors QMS procedures, work instructions, and job aids. Provides first level review for changes.
• Supports problem-solving solutions for system issues.
• Provides expertise for implementing, deactivation, monitoring, quality assurance, and reporting of prepay edits.
• Facilitates meetings and coordinates presentations.
• Tracks and analyzes data and reports for prepay committee edit effectiveness; creates presentations.
• Assigns incoming and outgoing external contractor communications; monitors completion of requests.
• Researches prepay and post-pay record questions. Reports quality assurance for appeal requests, recalculations, and redeterminations.
• Schedules coordination of ad hoc calls with external contractors or law enforcement; takes minutes.
• Reviews and comments on Medicare JOAs.
• Creates templates and content for the external contractor annual fraud and abuse training.

• Minimum Bachelor's Degree
• Minimum of 2-4 years experience in fraud investigation/detection ; 5-7 years experience preferred
• Must possess 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
• Medicare investigation experience strongly 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

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