Fraud Investigator - Advisor (Medicare & Medicaid)

SafeGuard Services (SGS), a subsidiary of Peraton, performs data analysis, investigation, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse.

We are looking to add an Investigative Team Lead to our SGS team of talented professionals

 What You’ll do:

This Fraud Investigator Advisor will support the prosecution of cases within the SE UPIC and act as a liaison between the SE UPIC, HHS OIG, State Medicaid Agencies (SMA), and the Department of Justice (DOJ). The selected candidate will be required to understand and develop expertise in Medicare and Medicaid policies to prepare cases for prosecution. The individual exercises significant independent judgment within broadly defined policies and practices to determine the best method for accomplishing work and achieving objectives.   

• Assist investigators with case development
• Must be responsive to requests from USAO, DOJ
• Extensive travel required within the USA
• Monitor timeliness for case updates and escalating to management as necessary
• Monitor the progress of investigations and cases to ensure use of all available remedies, i.e., suspension, pre-pay reviews, revocation, etc.
• Mentor team members so that they can identify previously undetected fraud, waste, or abuse through proactive or reactive research, analysis, and development.
• Conduct training on case development for prosecution, including best practices, and lessons learned
• Attend regional meetings with stakeholders, including HHS OIG, FBI, SMA’s, and other Federal/State agencies.
• Telework available from Eastern time zone

Basic Qualifications:

• Minimum of 8 years with BS/BA; Minimum of 6 years with MS/MA; Minimum of 3 years with PhD
• Healthcare investigative experience required.
• Previous experience testifying in Federal Court in related healthcare prosecutions.
• CFE or AHFI certification preferred
• Strong communication and organization skills
• Strong PC knowledge and skills
• Ability to travel within the US as needed
• Applicant must reside in the Eastern time zone
• Applicant must be a U.S. citizen

Desirable Qualifications:

The most competitive candidates will have:

• Knowledge of Medicaid requirements, laws, rules and regulations related to payment for services billed the Program
• Experience in reviewing claims, performing medical reviews, and/or developing fraud cases
• Documented experience working in a law enforcement environment specific to the Medicare and Medicaid Programs.
• Documented experience in preparing and testifying for cases associated with Medicare and Medicaid rules, policies, and program requirements.
• Master’s Degree preferred

Essential Functions:

• Ability to perform research and draw conclusions
• Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
• Ability to organize a case file, accurately and thoroughly document all steps taken
• Ability to compose correspondence, reports and referral summary letters
• Ability to educate providers, provider associations, law enforcement, other contractors and beneficiary advocacy groups on program safeguard matters
• Ability to communicate effectively, internally and externally
• Ability to interpret laws and regulations
• Ability to handle confidential material
• Ability to report work activity on a timely basis
• Ability to work independently and as a member of a team to deliver high quality work
• Ability to attend meetings, training, and conferences, overnight travel required
• Document QC results in WMM according to record type
• Coordinate with other designated leads if necessary, for coverage for periods where the lead is out of the office during work hours.