Auditor/Investigator II

Auditor/Investigator II - Overview

Qlarant is a not-for-profit corporation partnering with public and private sectors to deliver high quality, safe, and efficient healthcare and human services programs. Our business lines include population health, utilization review, managed care organization quality review, quality assurance for developmental disability programs, and national fraud, waste and abuse prevention. The Foundation also provides grant opportunities for underserved communities.

Job Summary

Monitors processing and reconciliation of electronic medical records, prepay claims, and operations reports. Supports research for prepay and post-pay record questions and misdirected document returns.

Essential Functions

• Monitor QMS procedures, work instructions, and job aids with first level review.
• Support problem-solving for system issues and prepay edits implementation.
• Facilitate meetings, coordinate presentations, and track data analysis for prepay committee edit effectiveness.
• Assign external contractor communications and monitor completion of requests.
• Research record questions and report quality assurance for appeals, recalculations, and redeterminations.
• Schedule ad hoc calls with external contractors or law enforcement and take minutes.
• Review and comment on Medicare JOAs.
• Create templates and content for external contractor annual fraud and abuse training.

Supervision and Experience

Works independently with managerial guidance for project prioritization. Requires a minimum Bachelor's Degree and 2-4 years of experience (5-7 preferred) in Healthcare Investigation. Medicare experience is preferred. Certified Fraud Examiner is a plus.

Key skills/competency

Health care, fraud, prepay, investigation, quality assurance, Medicare, compliance, data analysis, documentation, contractor management.