Supervisor - Audit/Investigation

Company Overview

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. The organization operates 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 and provides grant opportunities through its Foundation for underserved communities.

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 or 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 Functions

• Reviews new audits/investigations and/or incoming leads to determine appropriateness, assigns them to auditors/investigators, vets providers with appropriate agencies and law enforcement, and supervises the vetting process.
• Reviews audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to the team.
• Conducts regular file reviews of audits/investigations to confirm that plans are appropriate and that documentation is entered and summarized within case tracking systems.
• 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 audits/investigations, and site verification as needed.
• Leads audit/investigation projects, developing strategies, conducting stakeholder meetings, reviewing project actions for quality, and documenting findings in management reports.
• 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.) in case tracking systems and updates them 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 the course of action.
• Supervises and prepares the team’s audits/investigations for Major Case Coordination meetings and conducts quality‑assurance reviews.
• Initiates and maintains communications with law enforcement and regulatory agencies, presenting or assisting with presenting findings for further investigation, prosecution, or other regulatory remedies.
• Supervises administrative remedies per major case coordination direction (e.g., payment suspensions, revocations, provider education) and reviews them for quality assurance.
• Reviews and approves the closing summary of audits/investigations.
• Collects information and documentation requested by internal and external stakeholders (e.g., CMS, law enforcement, FOIA requests) and submits them 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 and the formal performance‑review process to ensure exceptional service delivery, engagement, motivation, and team development.

Education and Experience

• Minimum Bachelor’s degree required.
• 5–7 years of relevant experience required; 8–11 years preferred.

Certifications

• Certified Fraud Examiner (CFE) or Accredited Healthcare Anti‑fraud Investigator (AHAFI) certification preferred.

Level of Supervision Received

Drives work independently and escalates questions and issues as needed.