Intake Investigator Lead

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:

Qlarant is seeking an experienced Supervisor for our Audit/Investigation team to oversee critical operations related to Medicare and Medicaid fraud, waste, and abuse detection. This full-time, regular position based in our Los Alamitos, CA office offers a competitive annual salary range of $74,297 to $92,000, commensurate with experience and qualifications. As the Supervisor of Audit/Investigation, you will play a pivotal role in maintaining the integrity of healthcare programs by leading a team of auditors and investigators in identifying potential fraud, waste, and abuse. Your responsibilities will encompass comprehensive oversight of audit and investigation processes, ensuring adherence to established protocols and quality standards. This position may require up to 25% travel. The employment relationship is regular/at-will.

Essential Duties and Responsibilities:

• You will be responsible for reviewing new audits/investigations and incoming leads, determining their appropriateness, and assigning them to team members. A critical aspect of your role involves vetting providers with appropriate agencies and law enforcement, as well as supervising the entire vetting process. You'll review audit/investigation plans and priorities to ensure they align with the specific functions and workload assigned to your team.
• Regular file reviews will be conducted under your supervision to verify that audit/investigation plans are appropriate and that all documentation is properly entered and summarized within case tracking systems. You'll also review and approve information requests, data reports, and correspondence to maintain quality and appropriateness.
• Your hands-on approach will include supervising and conducting audit/investigation actions such as interviews, onsite audits/investigations, and site verifications as needed. You'll lead audit/investigation projects, develop strategies, conduct stakeholder meetings, review project actions for quality, and document findings in management reports.
• Effective communication with the Data and Medical Review departments will be essential to ensure efficient audits/investigations. You'll prepare and present audits/investigations, overpayments, and questions for stakeholder meetings, while documenting all relevant information in case tracking systems.
• A key responsibility will be determining the appropriateness of fraud, waste, and abuse issues according to pre-established criteria. You'll review investigative findings with your team and approve courses of action, while supervising and preparing team audits/investigations for Major Case Coordination meetings and quality assurance reviews.
• You'll initiate and maintain communications with law enforcement and appropriate regulatory agencies, presenting or assisting with presenting audit/investigation findings for their consideration. Supervision of administrative remedies in accordance with major case coordination direction will fall under your purview, as will reviewing and approving closing summaries of audits/investigations.
• The role requires collection and submission of information and documentation as requested by internal and external stakeholders, collaboration with other program integrity contractors, and potentially testifying at various legal or administrative proceedings.
• As a manager, you'll be responsible for team performance through regular feedback and formal performance reviews, ensuring exceptional service delivery, engagement, motivation, and team development.
• Reviews new audits/investigations and/or incoming leads to determine appropriateness and assigns to auditors/investigators; vets providers as required with appropriate agency(ies) and law enforcement; supervises vetting process. Reviews audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to team.
• Conducts file reviews regularly of audits/investigations to ensure audit/investigation plan is appropriate and the audit/investigation file documents are entered and summarized within the case tracking systems appropriately. 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 audit/investigation, and/or site verification as needed. Leads audit/investigation projects including developing an audit/investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management.
• 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.) into the case tracking systems and updates systems 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 course of action. Supervises and prepares team's audits/investigations for the Major Case Coordination meetings and reviews for quality assurance.
• Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting audit/investigation findings for their consideration to further audit/investigate, prosecute, or seek other appropriate regulatory or administrative remedies. Supervises administrative remedies in accordance with major case coordination direction (e.g. payment suspensions, revocations, provider education) and reviews for quality assurance. Reviews and approves closing summary of audit/investigation.
• Collects information and documentation as requested by internal and external stakeholders (e.g. CMS, law enforcement, FOIA requests) and submits, 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 as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.

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

• Execution and delivery skills (planning, delivering, and supporting)
• Business intelligence aptitude
• Problem solving and decision making skills
• Collaboration and teamwork abilities
• Case management expertise
• Knowledge of Medicare and Medicaid regulations
• Proficiency in fraud detection methodologies
• Strong analytical skills
• Excellent written and verbal communication
• Leadership and team management
• Attention to detail
• Project management capabilities
• Ability to testify in legal proceedings
• Proficiency with case tracking systems
• Stakeholder management experience

Education (education can be substituted for experience):

• Minimum Bachelor's Degree
• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred

Work Experience (experience can be substituted for education)

• Minimum of 5-7 years experience
• Minimum of 8-11 years experience preferred
• Experience supervising audit or investigation teams preferred 
• Background in Medicare/Medicaid program integrity preferred 
• Experience collaborating with law enforcement agencies preferred 
• History of managing complex investigations preferred 
• Experience in preparing and presenting findings to stakeholders preferred 
• Background in healthcare regulatory compliance preferred 
• Experience with administrative remedies in healthcare fraud cases preferred 
• Demonstrated ability to manage team performance preferred 
• Experience with case tracking systems and documentation preferred 
• Background in conducting interviews and site verifications preferred 
• Experience in quality assurance processes preferred 

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