Auditor/Investigator II

Qlarant; California (MO); On-site; USD 65,000 - 90,000; Full time

Job summary

Qlarant is seeking an Auditor/Investigator to ensure the integrity of claims processing, collect data for audits, and identify fraud, waste, and abuse. You will interview witnesses, review documentation, and prepare comprehensive reports for management.

Minimum Bachelor's Degree is required; 2–4 years experience is expected, with 5–7 years preferred. A Certified Fraud Examiner is preferred. Qlarant is an Equal Opportunity Employer and drug-free workplace.

Qualifications

• Minimum Bachelor's Degree required.
• 2–4 years of experience required; 5–7 years preferred.
• Certified Fraud Examiner preferred.

Responsibilities

• Conduct routine and impartial audits/investigations from start to closure into customer claims, ensuring accurate and fair assessments of claims validity.
• Provide customer service by addressing inquiries and concerns, and escalate audit/investigation when needed.
• Compile detailed, organized records of audit/investigation findings in compliance with legal requirements.
• Apply knowledge to identify and prevent fraudulent activities within claims processes.
• Conduct interviews with witnesses, claimants, and stakeholders to gather information.
• Communicate findings to internal teams and ensure proper processing in line with standards.
• Present audit results clearly to customers and stakeholders, managing expectations.
• Assist in training and supporting other auditors/investigators.

Skills

Auditing & investigations

Data analysis

Interviews & interviewing witnesses

Regulatory compliance

Attention to detail

Communication skills

Documentation & reporting

Customer service

Education

Bachelor's degree

Certified Fraud Examiner (preferred)

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

Ensures the integrity and accuracy of claims processes and protocols. Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Adheres to industry regulations and policies for managerial follow-up. Analyzes data in order to effectively assess the validity of claims. Provides accurate recommendations to management for claim resolution and closure. Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes.

Essential Functions

• Conducts routine and impartial audits/investigations from start to closure into customer claims, ensuring accurate and fair assessments of claims validity.
• Provides customer service by addressing inquiries and concerns, and escalates audit/investigation, as needed.
• Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements.
• Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process.
• Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims.
• Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards.
• Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
• Assists in providing training and support to other auditors/investigators, contributing to the continuous improvement of investigative processes.

Level of Supervision Received

Plans and arranges own work; works with manager to prioritize projects.

Education (can be substituted for experience)

Minimum Bachelor's Degree required

Work Experience (can be substituted for education)

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

Certification(s)

Certified Fraud Examiner 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.