Senior Healthcare Fraud Investigator

This is a fully remote position, open to applicants in District of Columbia, +1 more state.

📋 Description

• Assess and confirm discrepancies and prioritized leads identified through War Room analytics, which encompass Provider 360, anomaly detection, and network analysis.

• Formulate cases related to potential fraud, waste, and abuse by community care providers, including coordinated billing schemes.

• Create referral packages for the War Room to support possible administrative actions such as provider removals, referral holds, recoupments, and oversight referrals.

• Assist in generating weekly analytic reports and decision-ready case packages that include facts, analysis, recommendations, and traceability.

• Prepare workpapers for claim reviews and determination packages; implement case-file QA checklists and sampling plans.

• Aid in designing the complete case workflow from intake to closure, which includes defining roles, handoffs, SLAs, and escalation paths that align with CIRTS triage practices.

• Contribute to the development of intake and triage SOPs, case lifecycle and status taxonomy, and standard investigation templates.

• Maintain registers for overpayment, recovery, referral status, oversight, and tracking.

• Provide expert input on investigative subject matters including fraud, waste, and abuse typologies, rule logic, provider risk-scoring, and criteria for case prioritization.

• Conduct case documentation and evidence gathering solely under the direction of an active federal investigator; refrain from opening cases, making findings, or referral decisions.

• Collaborate with OIC staff, VA OIG, and VHA stakeholders.

• Support the creation of ad hoc white papers, outcome summaries, and leadership briefings.

• Assist in developing training materials, kaizen sessions, after-action debriefs, and knowledge transfer to enable VA staff to independently operate the War Room by the end of the contract.

⛳️ Requirements

• Bachelor’s degree in a relevant field.

• Over 8 years of experience in federal healthcare program integrity and fraud investigations, including Medicare/Medicaid and VHA healthcare fraud referrals and case development.

• Proficient understanding of the False Claims Act, Anti-Kickback Statute, Stark Law, Civil Monetary Penalties Law, and HHS OIG exclusion authorities.

• Excellent written and verbal communication skills suitable for executive-level audiences.

• Must be able to pass or currently hold a Tier 2 / Moderate Background Investigation (MBI).

• Certification as a Certified Fraud Examiner (CFE) is preferred.

• Current or previous access to VA/VHA systems, or active status as a VA contractor is desirable.

• Experience collaborating with HHS OIG, VA OIG, or other federal law enforcement on healthcare fraud referrals is preferred.

• Familiarity with VA Community Care claims, CMS program integrity data, or provider exclusion screening is desired.

• Experience using Palantir or similar analytics and case-management platforms is a plus.

• Familiarity with CIRTS or similar compliance case-tracking systems is advantageous.

• Understanding of GAO Green Book, OMB A-123, and Payment Integrity Act fraud risk frameworks is desired.

🏝️ Benefits

• Affirmative Action and Equal Opportunity Employer.

• Opportunity to work in a high-visibility role at the Veterans Health Administration Fraud Rapid Response Center supporting VA operations.

• Access to knowledge transfer and training opportunities through training materials, kaizen sessions, after-action debriefs, and knowledge transfer.