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Qlarant · 12 hours ago

Audit/Investigation Coordinator II

Los Alamitos, CA, US

Full-time

Onsite

Entry, Mid Level

2+ years exp

Qlarant is a not-for-profit corporation focused on improving healthcare delivery and fighting fraud in various sectors. The Audit/Investigation Coordinator II will evaluate complaints and investigate potential fraud cases related to Medicare and Medicaid, ensuring accurate data tracking and compliance with established procedures.

Information ServicesInformation Technology

Responsibilities

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