Audit/Investigation Coordinator II

Job Summary

Performs in-depth evaluation and makes field level judgments related to complaints and investigative leads of potential fraud investigations (e.g. Medicare and/or Medicaid) that meet established criteria for referral to the appropriate agency(ies) for administrative action or law enforcement.

Essential Functions

• Reviews complaint data including allegations, subjects of the complaint, and facts of the complaint to ensure case tracking system is correctly populated and updated per pre-established timeframes.

• Maintains data records in the case tracking systems to ensure timely processing of cases.

• Screens incoming fraud leads by extracting information from sites related to the subject(s), utilizing a variety of resources and systems to capture the scope of fraud, and evaluating relevant legislation to draft a case file that is comprehensive and accurate.

• Confers with complainants and beneficiaries, as needed, to obtain clarification regarding complaints and to verify services to assist in drafting contact reports.

• Operates systems to obtain claims, enrollment, and provider/beneficiary information.

• Prepares intake investigation report, collecting all relevant facts, risks, and leads to recommend investigations to Lead Investigator.

• Processes requests for information (RFIs), as needed, to various contractors, reviews information upon receipt, and incorporates findings into audit/investigation file to ensure thorough audit/investigation files are delivered.

• Recommends opportunities to improve fraud audit/investigation processes and procedures ensuring industry best practices are being followed.

Education

Minimum High School Diploma or GED required

Work Experience

2 - 4 years of experience required; 5 - 7 years preferred

Company Information

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities. Qlarant is a drug-free workplace.