Supervisor - Audit/Investigation

Qlarant; New York (NY); On-site; USD 90,000 - 130,000; Full time

Job summary

Qlarant is a not-for-profit organization delivering quality health and human services programs across public and private sectors. The role oversees audits/investigations related to Medicare fraud, waste and abuse and guides field-level judgments on referrals to agencies or law enforcement.

The position requires leadership in project management, collaboration with data and medical review teams, and the ability to present findings.

Qualifications

• Minimum Bachelor's Degree required.
• 5–7 years of audit/investigation experience.
• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred.

Responsibilities

• Oversees audits/investigations workload and assigns to staff.
• Supervises vetting with appropriate agencies and law enforcement.
• Reviews audit/investigation plans, conducts file reviews, and ensures data entry into tracking systems.
• Leads audit/investigation projects and documents findings for management.
• Testifies at proceedings and communicates results to stakeholders.

Skills

Audits & investigations

Supervisory experience

Stakeholder communication

Interviews

Education

Bachelor's degree

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

Oversees audits/investigations and audit/investigation workload. Performs in-depth evaluation and makes field level judgments related to audits/investigations of potential Medicare fraud waste and abuse audits/investigations or cases compliance cases (e.g. Medicare and/or Medicaid) that meet established criteria for referral to the appropriate agency(ies) for administrative action or to law enforcement for criminal action.

Essential Functions

Reviews new audits/investigations and/or incoming leads to determine appropriateness and assigns to auditors/investigators; vets providers as required with appropriate agency(ies) and law enforcement; supervises vetting process. Reviews audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to team. Conducts file reviews regularly of audits/investigations to ensure audit/investigation plan is appropriate and the audit/investigation file documents are entered and summarized within the case tracking systems appropriately. Reviews auditor/investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness. Supervises and conducts audit/investigation actions such as interviewing, onsite audit/investigation, and/or site verification as needed. Leads audit/investigation projects including developing an audit/investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management. Communicates with the Data and Medical Review departments to ensure efficient audits/investigations. Prepares and presents audits/investigations, overpayments, and questions for stakeholder meetings. Documents audit/investigation information and file reviews (interviews, events, findings, communications, etc.) into the case tracking systems and updates systems as needed. Determines audit/investigation appropriateness of fraud, waste, and abuse issues in accordance with pre-established criteria. Reviews audit/investigative findings with auditors/investigators and approves course of action. Supervises and prepares team’s audits/investigations for the Major Case Coordination meetings and reviews for quality assurance. Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting audit/investigation findings for their consideration to further audit/investigate, prosecute, or seek other appropriate regulatory or administrative remedies. Supervises administrative remedies in accordance with major case coordination direction (e.g. payment suspensions, revocations, provider education) and reviews for quality assurance. Reviews and approves closing summary of audit/investigation. Collects information and documentation as requested by internal and external stakeholders (e.g. CMS, law enforcement, FOIA requests) and submits, as required. Collaborates with other program integrity contractors, as needed. Testifies at various legal or administrative proceedings, as necessary. Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.

Level of Supervision Received

Drives work independently and escalates questions and issues, as needed

Education (can be substituted for experience): Minimum Bachelor's Degree required

Work Experience (can be substituted for education): 5 - 7 years of experience required; 8 - 11 years preferred

Certification(s): Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification 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.