Healthcare Fraud Investigator I

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:

Serves as an entry level professional who develops baseline plans for ensuring the integrity and accuracy of claims processes and protocols. Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Adheres to industry regulations and company policies for managerial follow-up. Analyzes data in order to effectively assess the validity of claims. Provides accurate recommendations to management for claim resolution and closure. Documents and inputs all findings, while preparing comprehensive reports that may be used for legal or audit/investigative purposes.

Essential Duties and Responsibilities include some or all of the following. Other duties may be assigned.

• Conducts routine and impartial audits/investigations into customer claims, ensuring accurate and fair assessments of claims validity.
• Provides customer service by addressing inquiries and concerns, and escalates audit/investigation, as needed.
• Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements.
• Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process.
• Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims.
• Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards.
• Ensures that all audit and investigative documents and records are processed into the database in a timely and accurate manner.
• Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates.
• Supports management in regular audit and investigation proceedings, ensuring full compliance with all applicable regional and federal standards, regulations, and protocols.

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 - Small, but direct impact through the quality of the tasks/service provided by the individual.
• Area of Impact - Primarily on own department.
• Interpersonal Skills - Information exchange requiring tact and diplomacy is a significant feature of the job.
• Leadership - This job has no supervisory responsibilities.
• Functional Knowledge - Good understanding of procedures and concepts within own discipline.
• Project Management - Project/program team member.

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 0-2 years experience
• Minimum of 2-4 years experience preferred

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