Audit/Investigation Coordinator II

Qlarant; Texas; On-site; USD 60,000 - 90,000; Full time

Job summary

Qlarant is a not-for-profit organization dedicated to safeguarding health care programs across the country. This role involves evaluating complaints and investigative leads related to potential fraud, referring cases to the appropriate agency for action, and supporting the investigative team.

Under close supervision, you will review data, maintain case records, and draft intake reports. The position requires strong analytical skills and attention to detail in a fast-paced environment.

Qualifications

• Minimum 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 on schedule.
• Maintains data records in case tracking systems for timely processing.
• Screens fraud leads by extracting information from sites and evaluating relevant legislation to draft a comprehensive file.
• Confers with complainants and beneficiaries to obtain clarification and verify services.
• Operates systems to obtain claims, enrollment, and provider/beneficiary information.
• Prepares intake investigation report with relevant facts, risks, and leads.
• Processes RFIs to contractors and incorporates findings into the investigation file.
• Offers opportunities to improve fraud audit/investigation processes and procedures.

Skills

Fraud investigation

Data extraction

Case management

Communication with complainants

Education

High School Diploma or GED

Healthcare or insurance industry experience preferred

Medicare/Medicaid experience a plus

Tools

Case tracking systems

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 country. In addition, our Foundation provides grant opportunities to those with programs for underserved 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 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 (can be substituted for experience):

Minimum High School Diploma or GED required

Healthcare or insurance industry experience preferred

Medicare/Medicaid experience a plus.

Work Experience (can be substituted for education):

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.