Supervisor - Audit/Investigation

Qlarant•Pontedeume, AR

6d•$66,285 - $92,000

About The Position

Qlarant is a not-for-profit corporation that partners with public and private sectors to support high-quality, safe, and efficient health care and human services programs. Its work includes population health, utilization review, managed care organization quality review, quality assurance for programs serving individuals with developmental disabilities, and efforts to fight fraud, waste, and abuse. Its Foundation provides grant opportunities to programs serving underserved communities. The Supervisor - Audit/Investigation oversees audits, investigations, and team workload. The role performs in-depth evaluations and makes field-level judgments involving potential Medicare fraud, waste, and abuse, as well as program compliance cases, including Medicare and/or Medicaid cases. The supervisor determines which cases meet established criteria for referral to appropriate agencies for administrative action or to law enforcement for criminal action. The position drives work independently and escalates questions and issues as needed. The supervisor reviews and assigns incoming audits, investigations, and leads; oversees provider vetting; and ensures plans, priorities, files, requests, and correspondence are appropriate and of high quality. The role may conduct interviews, onsite audits or investigations, and site verifications, and leads projects by developing strategies, coordinating stakeholder meetings, reviewing project actions, and documenting findings. The position coordinates with Data and Medical Review departments, regulatory agencies, law enforcement, stakeholders, and other program integrity contractors. It documents case information, evaluates findings, approves courses of action and closing summaries, oversees administrative remedies, prepares cases for major case coordination meetings, and submits requested documentation. The supervisor may present findings, testify in legal or administrative proceedings, and manages team performance, feedback, reviews, engagement, and development.

Requirements

Bachelor’s degree required; education may be substituted for experience.
5–7 years of experience required; experience may be substituted for education.
Ability to drive work independently and escalate questions and issues as needed.

Nice To Haves

8–11 years of experience preferred.
Certified Fraud Examiner certification preferred.
Accredited Healthcare Anti-fraud Investigator Certification preferred.

Responsibilities

Review new audits, investigations, and incoming leads for appropriateness and assign them to auditors or investigators.
Vet providers with appropriate agencies and law enforcement as required, and supervise the vetting process.
Review audit and investigation plans and priorities to ensure they are appropriate and meet quality standards for the team’s workload.
Conduct regular file reviews to ensure plans are appropriate and case documents are entered and summarized correctly in case tracking systems.
Review auditor and investigator requests for information, data, and reports, as well as correspondence, for quality and appropriateness.
Supervise and conduct interviews, onsite audits or investigations, and site verification as needed.
Lead audit and investigation projects by developing strategies, conducting stakeholder meetings, reviewing project actions for quality, and documenting findings in reports for management.
Communicate with Data and Medical Review departments to support efficient audits and investigations.
Prepare and present audits, investigations, overpayments, and questions for stakeholder meetings.
Document case information and file reviews, including interviews, events, findings, and communications, in case tracking systems, and update systems as needed.
Determine whether fraud, waste, and abuse issues warrant audit or investigation under established criteria.
Review findings with auditors and investigators and approve the course of action.
Supervise and prepare the team’s audits and investigations for Major Case Coordination meetings and review them for quality assurance.
Maintain communications with law enforcement and regulatory agencies, including presenting or assisting in presenting findings for consideration of further investigation, prosecution, or other remedies.
Supervise administrative remedies in accordance with major case coordination direction, such as payment suspensions, revocations, and provider education, and review them for quality assurance.
Review and approve audit or investigation closing summaries.
Collect and submit information and documentation requested by internal and external stakeholders, including CMS, law enforcement, and FOIA requesters.
Collaborate with other program integrity contractors as needed.
Testify at legal or administrative proceedings as necessary.
Manage team performance through regular, timely feedback and formal performance reviews to support service delivery, engagement, motivation, and team development.