审计/调查协调员 II
Audit/Investigation Coordinator II
Qlarant 是一家非营利性公司，与公共和私营部门合作，创建高质量、安全且高效的医疗保健和人类服务项目交付。我们有多个业务线，包括人口健康、使用审查、管理护理组织质量审查以及为发展障碍人士提供服务项目的质量保证。Qlarant 也是全国范围内为大型组织打击欺诈、浪费和滥用行为的领先者。此外，我们的基金会为服务于弱势社区的项目提供资助机会。
最佳人才，最佳解决方案，最佳成果
职位摘要：
对涉及欺诈调查的投诉和调查线索进行深入评估，并在现场层面做出判断（例如 Medicare 和/或 Medicaid），这些线索符合转交相关机构进行行政行动或执法的既定标准。
主要职责：
- 审查投诉数据，包括指控、投诉对象和投诉事实，确保案件跟踪系统正确填写并按预设时间表更新。
- 在案件跟踪系统中维护数据记录，以确保案件及时处理。
- 通过从相关网站提取与涉案人员有关的信息，利用多种资源和系统来捕捉欺诈范围，并评估相关法规，以起草全面准确的案件文件。
- 在需要时与投诉人和受益人沟通，以获取关于投诉的澄清，并核实服务信息，以协助起草联系报告。
- 操作系统以获取索赔、注册和供应商/受益人信息。
- 准备初步调查报告，收集所有相关事实、风险和线索，向主调查员推荐调查。
- 处理信息请求（RFI），根据需要向各承包商提出，收到信息后进行审查，并将发现纳入审计/调查文件，以确保提供全面的审计/调查文件。
- 建议改进欺诈审计/调查流程和程序的机会，确保遵循行业最佳实践。
接受的监督程度：
在密切监督下工作，与经理紧密合作以确定优先事项。
教育背景（可由经验替代）：
最低高中文凭
查看英文原文
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 underserved communities.
Best People, Best Solutions, Best Results
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.
Level of Supervision Received:
Under close supervision, works closely with manager to prioritize efforts.
Education (can be substituted for experience):
Minimum High School Diploma or GED required
Work Experience (can be substituted for education):
2 - 4 years of experience required; 5 - 7 years preferred
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.
Originally posted on Himalayas