Auditor/Investigator 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:

Monitors the processing and reconciliation of incoming electronic medical records, importing of prepay claims and records, and generating other operation reports related to process of prepay claims. Supports research of prepay and post-pay record questions as well as research and return of misdirected documents. Position will be on the Medicaid team.

Essential Duties and Responsibilities:

• Monitors QMS procedures, work instructions, and job aids. Provides first level review for changes.
• Supports problem-solving solutions for system issues.
• Provides expertise for implementing, deactivation, monitoring, quality assurance, and reporting of prepay edits.
• Facilitates meetings and coordinates presentations.
• Tracks and analyzes data and reports for prepay committee edit effectiveness; creates presentations.
• Assigns incoming and outgoing external contractor communications; monitors completion of requests.
• Researches prepay and post-pay record questions. Reports quality assurance for appeal requests, recalculations, and redeterminations.
• Schedules coordination of ad hoc calls with external contractors or law enforcement; takes minutes.
• Reviews and comments on Medicare JOAs.
• Creates templates and content for the external contractor annual fraud and abuse training.

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

• Business Expertise- Good understanding of how the team integrates with others in accomplishing the objectives of the department.
• Problem Solving- Uses judgment based on practice and precedence.
• Nature of Impact- Small, but direct impact through the quality of the tasks/service provided by the individual.
• Area of Impact- Primarily on closely related departments.
• Interpersonal Skills- Developed communication skills to exchange complex information.
• Leadership- No supervisory responsibility, but the job provides on-the-job training/support to new team members.
• Functional Knowledge- Good understanding of concepts and procedures within own discipline and basic knowledge of these elements in other disciplines.
• Project Management- Project/program team member.

Education (education can be substituted for experience):

• Minimum Bachelor's Degree
• Certified Fraud Examiner preferred

Work Experience (experience can be substituted for education)

• Minimum of 2-4 years experience
• Minimum of 5-7years experience preferred
• Experience with Medicaid and healthcare fraud investigations preferred

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