Supervisor - Field Audit/Investigation

Qlarant; United States; On-site; USD 90,000 - 140,000; Full time

Job summary

Qlarant is seeking an experienced professional to oversee audits and investigations related to potential government program fraud, waste, and abuse. The role involves evaluating case criteria, directing staff, and coordinating with law enforcement and regulatory agencies to determine appropriate actions.

The ideal candidate will have a Bachelor's degree, 5–7 years of experience (8–11 preferred), and may hold a CFE or Accredited Healthcare Anti-fraud Investigator Certification.

Qualifications

• Bachelor's degree required.
• 5€“7 years of experience required; 8€“11 years preferred.
• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred.

Responsibilities

• Reviews new audits/investigations and assigns to auditors/investigators; vets providers and law enforcement as required; supervises vetting process.
• Conducts file reviews to ensure plan/operational alignment and proper documentation in case tracking systems.
• Supervises audit/investigation actions such as interviewing, onsite investigations, site verification, and liaison with law enforcement.
• Prepares and summarizes audits/investigations for senior leadership and stakeholder meetings.
• Collaborates with law enforcement and regulatory agencies; presents findings for further action.
• Manages team performance through regular feedback and formal performance reviews.

Education

Bachelor's degree

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 government program fraud waste and abuse audits/investigations or cases compliance cases (e.g. Medicare, Medicaid, and/or Supplemental Nutrition Assistance Program) 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 and assigns to auditors/investigators; vets providers and/or retailers as required with appropriate agency(ies) and law enforcement; supervises vetting process. Reviews audit/investigation plans/operations 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/operation 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, site verification, and liaison with law enforcement 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 all involved divisions, such as senior leadership and/or the Data and Medical Review departments to ensure efficient audits/investigations. Prepares, presents, and summarizes 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 presentation to the customer, e.g., 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 customer direction, e.g., major case coordination direction such as payment suspensions, revocations, or 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, USDA, 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):

Bachelor's degree required

Experience (can be substituted for education):

5 - 7 years required; 8 - 11 years preferred

Certifications:

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.