Audit/Investigator Coordinator II
Audit/Investigator Coordinator II
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Job Description
Qlarant is 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. Qlarant is also a national leader in fighting fraud waste and abuse for large organizations across the addition our Foundation provides grant opportunities to those with programs for under-served communities.
Best People Best Solutions Best Results
Job Summary:
Performs in-depth evaluation and makes field level judgments related to complaints and investigative leads of potential fraud investigations (e.g. Medicare and/or Medicaid) that meet established criteria for referral to the appropriate agency(ies) for administrative action or law enforcement.
Essential Duties and Responsibilities:
- Reviews complaint data including allegations subjects of the complaint and facts of the complaint to ensure case tracking system is correctly populated and updated per pre-established timeframes.
- Maintains data records in the case tracking systems to ensure timely processing of cases.
- Screens incoming fraud leads by extracting information from sites related to the subject(s) utilizing a variety of resources and systems to capture the scope of fraud and evaluating relevant legislation to draft a case file that is comprehensive and accurate.
- Confers with complainants and beneficiaries as needed to obtain clarification regarding complaints and to verify services to assist in drafting contact reports.
- Operates systems to obtain claims enrollment and provider/beneficiary information.
- Prepares intake investigation report collecting all relevant facts risks and leads to recommend investigations to Lead Investigator.
- Processes requests for information (RFIs) as needed to various contractors reviews information upon receipt and incorporates findings into audit/investigation file to ensure thorough audit/investigation files are delivered.
- Recommends opportunities to improve fraud audit/investigation processes and procedures ensuring industry best practices are being followed.
Required Skills
To perform the job successfully an individual should demonstrate the following competencies:
- Business Expertise- Basic understanding of how the team integrates with others in accomplishing the objectives of the department.
- Problem Solving- Selects appropriate alternatives from defined options in a variety of work routines.
- Nature of Impact- Small but direct impact through the quality of the tasks/service provided by the individual.
- Area of Impact- Primarily on closely related work teams.
- Interpersonal Skills- Information exchange requiring tact and diplomacy is a significant feature of the job.
- Leadership- No supervisory responsibility but the job provides on-the-job training/support to new team members.
- Functional Knowledge- Full knowledge of activities and procedures of own job.
- Project Management- Project/program team member.
Required Experience:
IC
Employment Type
Full-Time
