Intake 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:

Independently performs in-depth evaluation and makes field level judgments related to complaints and proactive leads of potential Medicare fraud investigations that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Enters investigative information into the case tracking systems and will meet with Lead Investigators to assign investigations to the Investigative team.
• Works with the team to prioritize complaints for investigations.
• Places potential fraudulent providers on prepay review and monitor adjudication of claims.
• Analyzes data for appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria, requesting additional documentation if necessary.
• Refers all potential adverse decisions to the Lead Investigator/Manager.
• Identifies, collects, preserves, analyzes and summarizes evidence, examining records, verifying authenticity of documents, preparing affidavits or supervising the preparation of affidavits as needed.
• Drafts and evaluates investigation reports and promote effective and efficient investigations.
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
• Testifies at various legal proceedings as necessary.
• Communicates with beneficiaries and providers as needed to resolve beneficiary complaints and assists providers with medical review status.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.

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

• Ability to work independently with minimal supervision.
• Ability to communicate effectively with all members of the team to which he/she is assigned.
• Ability to grasp and adapt to changes in procedure and process.
• Ability to effectively resolve complex issues.

Education and/or Experience:

• An Associate's Degree
• Certification in an applicable program such as Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification
• Experience in health care fraud investigation/detection.
• Experience in a federal or state healthcare programs
• Experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.

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