[Hiring] Supervisor - Audit/Investigation @Qlarant

Role Description

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 audits/investigations or cases 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 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.

Qualifications

• Minimum Bachelor's Degree required.

Requirements

• 5 - 7 years of experience required; 8 - 11 years preferred.
• Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred.

Benefits

• Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.
• Qlarant is a drug-free workplace.
• All offers of employment are contingent upon successful completion of pre-employment background and drug screens.