Audit/Investigation Coordinator II

Qlarant; Dallas (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

Qlarant is seeking a detail-oriented investigator to perform in-depth reviews of complaints and investigative leads related to potential fraud in Medicare/Medicaid programs. You will support field judgments and escalate cases to Lead Investigator as needed.

Under close supervision, you will work with the manager to prioritize tasks, maintain case records, and draft comprehensive reports for administrative action or law enforcement referral.

Qualifications

• High School Diploma or GED required.
• Healthcare or insurance industry experience preferred.
• Medicare/Medicaid experience a plus.

Responsibilities

• Reviews complaint data to ensure case tracking is correctly populated and updated.
• Maintains data records in case tracking systems for timely processing.
• Screens incoming fraud leads by extracting information from sources to draft a comprehensive case file.
• Communicates with complainants and beneficiaries to obtain clarification and verify services.
• Operates systems to obtain claims, enrollment, and provider/beneficiary data.
• Prepares intake investigation report with relevant facts, risks, and leads.

Skills

Fraud investigation

Data review

Case management

Communication

Attention to detail

Education

High School Diploma or GED

Healthcare/insurance experience

Medicare/Medicaid experience

Job description

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 Functions

• 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.

Level of Supervision Received

Under close supervision, works closely with manager to prioritize efforts.

Education

Minimum High School Diploma or GED required.

Healthcare or insurance industry experience preferred.

Medicare/Medicaid experience a plus.

Work Experience

2-4 years of experience required; 5-7 years preferred.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

Qlarant is a drug‑free workplace. All offers of employment are contingent upon successful completion of pre‑employment background and drug screens.