Senior Fraud Investigator

Summary

Senior Healthcare Fraud InvestigatorArlo Solutions is supporting the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Office of Integrity and Compliance (OIC) in standing up and running the VHA Fraud Rapid Response Center ("VA War Room"). The War Room uses data analytics, fraud risk assessment and fast administrative action to protect Veterans and taxpayer dollars, in line with Executive Orders 14395 and 14243. The role is advisory and analytical. All final decisions stay with Government personnel.Location: REMOTE - Local to Washington, DCClearance: Minimum Background InvestigationResponsibilities and/or Success Factors:Fraud Lead & Case Development:Review and validate anomalies and prioritized leads from the War Room analytics (including Provider 360, anomaly detection and network analysis).Develop cases for potential community care provider fraud, waste and abuse (FWA) and coordinated billing schemes.Referral Package Development:Build War Room referral packages with documentation that supports potential administrative actions, such as provider removals, referral holds, recoupments and referrals to oversight bodies.Weekly Decision Packages:Help produce weekly analytic runs and decision-ready case packages that include facts, analysis, a recommendation and traceability.Claim Review Workpapers:Prepare claim review workpapers and determination packages and apply case-file QA checklists and sampling plans.Case Management Workflow:Help design the end-to-end case workflow from intake to closure, including roles, handoffs, SLAs and escalation paths, aligned with CIRTS triage practices.Contribute to the intake and triage SOPs, the case lifecycle and status taxonomy, and standard investigation templates.Overpayment & Referral Tracking:Keep the overpayment, recovery and referral status tracking register and the oversight and tracking log up to date.Algorithm & Scheme Input:Give investigative subject-matter input on FWA scheme typologies, rule logic, provider risk-scoring and case-prioritization criteria.Federal Investigator Direction (IGF Boundary):Do case documentation and evidence work only under real, active direction from a federal investigator. No opening cases, making findings or making referral decisions.Stakeholder Collaboration:Work closely with OIC staff, VA OIG and VHA stakeholders.Support ad hoc white papers, outcome summaries and leadership briefings.Knowledge Transfer:Help with training materials, kaizen sessions, after-action debriefs and knowledge transfer so VA staff can run War Room operations on their own by contract end.Minimum Qualifications Including Certificates:Bachelor's degree in a relevant field - 8+ years of federal healthcare program integrity and fraud investigations experience, such as Medicare/Medicaid and VHA healthcare fraud referrals and case developmentWorking knowledge of healthcare fraud law: the False Claims Act, Anti-Kickback Statute, Stark Law, Civil Monetary Penalties Law and HHS OIG exclusion authoritiesStrong written and verbal communication for executive-level audiencesAble to pass or hold a Tier 2 / Moderate Background Investigation (MBI)Desired Qualifications:Certified Fraud Examiner (CFE) certificationCurrent or prior VA/VHA system access, or current active VA contractor statusExperience working with HHS OIG, VA OIG or other federal law enforcement on healthcare fraud referralsExperience with VA Community Care claims, CMS program integrity data or provider exclusion screeningFamiliarity with Palantir or similar analytics and case-management platformsExperience with CIRTS or similar compliance case-tracking systems Knowledge of GAO Green Book, OMB A-123 and Payment Integrity Act fraud risk frameworksAAP StatementWe are proud to be an Affirmative Action and Equal Opportunity Employer and as such, we evaluate qualified candidates in full consideration without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, age, disability status, protected veteran status, and any other protected status.

Job Description

Senior Healthcare Fraud InvestigatorArlo Solutions is supporting the Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Office of Integrity and Compliance (OIC) in standing up and running the VHA Fraud Rapid Response Center ("VA War Room"). The War Room uses data analytics, fraud risk assessment and fast administrative action to protect Veterans and taxpayer dollars, in line with Executive Orders 14395 and 14243. The role is advisory and analytical. All final decisions stay with Government personnel.Location: REMOTE - Local to Washington, DCClearance: Minimum Background InvestigationResponsibilities and/or Success Factors:Fraud Lead & Case Development:Review and validate anomalies and prioritized leads from the War Room analytics (including Provider 360, anomaly detection and network analysis).Develop cases for potential community care provider fraud, waste and abuse (FWA) and coordinated billing schemes.Referral Package Development:Build War Room referral packages with documentation that supports potential administrative actions, such as provider removals, referral holds, recoupments and referrals to oversight bodies.Weekly Decision Packages:Help produce weekly analytic runs and decision-ready case packages that include facts, analysis, a recommendation and traceability.Claim Review Workpapers:Prepare claim review workpapers and determination packages and apply case-file QA checklists and sampling plans.Case Management Workflow:Help design the end-to-end case workflow from intake to closure, including roles, handoffs, SLAs and escalation paths, aligned with CIRTS triage practices.Contribute to the intake and triage SOPs, the case lifecycle and status taxonomy, and standard investigation templates.Overpayment & Referral Tracking:Keep the overpayment, recovery and referral status tracking register and the oversight and tracking log up to date.Algorithm & Scheme Input:Give investigative subject-matter input on FWA scheme typologies, rule logic, provider risk-scoring and case-prioritization criteria.Federal Investigator Direction (IGF Boundary):Do case documentation and evidence work only under real, active direction from a federal investigator. No opening cases, making findings or making referral decisions.Stakeholder Collaboration:Work closely with OIC staff, VA OIG and VHA stakeholders.Support ad hoc white papers, outcome summaries and leadership briefings.Knowledge Transfer:Help with training materials, kaizen sessions, after-action debriefs and knowledge transfer so VA staff can run War Room operations on their own by contract end.Minimum Qualifications Including Certificates:Bachelor's degree in a relevant field - 8+ years of federal healthcare program integrity and fraud investigations experience, such as Medicare/Medicaid and VHA healthcare fraud referrals and case developmentWorking knowledge of healthcare fraud law: the False Claims Act, Anti-Kickback Statute, Stark Law, Civil Monetary Penalties Law and HHS OIG exclusion authoritiesStrong written and verbal communication for executive-level audiencesAble to pass or hold a Tier 2 / Moderate Background Investigation (MBI)Desired Qualifications:Certified Fraud Examiner (CFE) certificationCurrent or prior VA/VHA system access, or current active VA contractor statusExperience working with HHS OIG, VA OIG or other federal law enforcement on healthcare fraud referralsExperience with VA Community Care claims, CMS program integrity data or provider exclusion screeningFamiliarity with Palantir or similar analytics and case-management platformsExperience with CIRTS or similar compliance case-tracking systems Knowledge of GAO Green Book, OMB A-123 and Payment Integrity Act fraud risk frameworksAAP StatementWe are proud to be an Affirmative Action and Equal Opportunity Employer and as such, we evaluate qualified candidates in full consideration without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, age, disability status, protected veteran status, and any other protected status.