Investigator Lead

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:

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 Duties and Responsibilities:

• 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.

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- Direct impact by ensuring the quality of the tasks/services/information provided by self and others.
• Area of Impact- Primarily on closely related work teams.
• Interpersonal Skills- Developed communication skills to exchange complex information.
• Leadership- Allocates work as a team leader; may check on completion/quality.
• Functional Knowledge- Good understanding of concepts and procedures within own discipline and basic knowledge of these elements in other disciplines.
• Project Management- Lead project/program team member checking the work of others. Typically responsible for training and developing new team members

Education (education can be substituted for experience):

• Minimum Bachelor's Degree
• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator preferred

Work Experience (experience can be substituted for education)

• Minimum of 5-7 years experience
• Minimum of 8-11 years experience preferred

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