Audit/Investigation Coordinator II

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 under-served communities.

Best People, Best Solutions, Best Results

Job Summary:

Qlarant is seeking a dedicated and analytical Audit/Investigation Coordinator II to join our team in the MD Easton Office. This full-time, regular/at-will position is ideal for an entry-level professional with a keen interest in combating healthcare fraud, particularly within Medicare and Medicaid programs. The Audit/Investigation Coordinator II will perform in-depth evaluations and make field-level judgments on complaints and investigative leads that indicate potential fraud. The role requires meticulous attention to detail to ensure that all complaint data, including allegations, subjects, and facts, are accurately recorded and updated in the case tracking system within pre-established timeframes. The successful candidate will maintain data records to ensure timely case processing and screen incoming fraud leads by extracting information from various resources to capture the scope of fraud. This includes evaluating relevant legislation to draft comprehensive and accurate case files. The coordinator will also interact with complainants and beneficiaries to clarify complaints and verify services, aiding in the drafting of contact reports. Operating systems to obtain claims, enrollment, and provider/beneficiary information is a key part of the role, as is preparing intake investigation reports that collect all relevant facts, risks, and leads to recommend investigations to the Lead Investigator. Additionally, the coordinator will process requests for information to various contractors, review the information upon receipt, and incorporate findings into the audit/investigation file. The role also involves recommending improvements to fraud audit/investigation processes and procedures to ensure adherence to industry best practices.

Essential Duties and Responsibilities:

• 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.

To perform the job successfully, an individual should demonstrate the following competencies:

Education (education can be substituted for experience):

• Minimum High School Diploma or GED

Work Experience (experience can be substituted for education)

• Minimum of 2-4 years experience
• Minimum of 5-7 years experience preferred
• Experience with healthcare fraud investigations, particularly in Medicare and Medicaid, is highly desirable
• Experience in processing and reviewing requests for information in a legal or audit context preferred
• Proven track record of maintaining accurate data records and managing case tracking systems preferred

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