Healthcare Fraud investigator II (UPIC-West)

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:

As an Auditor/Investigator II, you will serve as a subject matter expert in implementing, deactivating, monitoring, and reporting on prepay edits, ensuring quality assurance throughout these processes. Your analytical skills will be put to use as you track and analyze data related to prepay committee edit effectiveness, creating comprehensive presentations based on your findings. You will also be tasked with researching both prepay and post-pay record questions, providing solutions to system issues, and ensuring the proper return of any misdirected documents. This role requires excellent communication skills as you will be facilitating meetings, coordinating presentations, and serving as a liaison for external contractor communications. You will be responsible for assigning and monitoring the completion of incoming and outgoing requests, as well as scheduling and coordinating ad hoc calls with external contractors or law enforcement agencies. During these interactions, you will be expected to take detailed minutes and ensure all parties are properly informed.

Quality assurance is a key component of this position. You will be monitoring QMS procedures, work instructions, and job aids, providing first-level review for any proposed changes. Additionally, you will be responsible for reporting quality assurance for appeal requests, recalculations, and redeterminations, as well as reviewing and commenting on Medicare JOAs. The position also involves creating templates and content for external contractor annual fraud and abuse training, demonstrating your ability to develop educational materials that effectively communicate complex compliance requirements.

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:

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 5-7 years experience preferred
• Experience with electronic medical records systems preferred
• Background in prepay and post-pay claims processing preferred
• Experience in healthcare compliance or fraud prevention preferred
• History of coordinating with external contractors or agencies preferred
• Experience in quality assurance reporting preferred
• Background in creating and delivering presentations preferred
• Experience with data tracking and analysis preferred
• Knowledge of Medicare processes and procedures preferred
• Bachelor's degree in healthcare administration, business, accounting, or related field preferred
• Demonstrated ability to manage multiple priorities simultaneously preferred
• Experience working in a remote or distributed team environment preferred

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