Intake Investigator
Job Location
4426 W Cerritos Ave, Los Alamitos, California
Position Type
Full-Time/Regular
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: Entry level Intake Investigator independently performs in-depth evaluation and makes field level judgments related to complaints and proactive leads of potential Medicare fraud investigations that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action. Essential Duties and Responsibilities include the following. Other duties may be assigned.
- Assess the assigned complaint (lead) for accuracy, (e.g., allegation, correct subject(s) for the complaint), and ensure case tracking system is correctly populated and updated per pre-established timeframes.
- Enters proactive data records into the case tracking systems.
- Develops incoming proactive and reactive leads; reads and understands allegations presented
- Conducts research and review which may include communication with external stakeholders (e.g., providers, complainants, law enforcement), extracts information from specific sites relative to the subject(s) and allegation(s), utilizes CMS data systems to identify possible related subjects to capture the scope of the fraud scheme and additional subject(s), reviews and analyzes applicable regulations and acquires and analyzes data for indications of fraud, waste and abuse issues in accordance with pre-established criteria. Evaluates risk and prioritizes lead.
- Interviews complainants and beneficiaries to resolve complaints and to verify services; drafts contact reports.
- Utilizes systems to obtain claims, enrollment, and provider/beneficiary information to analyze information for billing, background, links, and fraud indicators.
- Develops intake investigation report, and recommends investigations to Lead Investigator
- Prepares requests for information (RFIs) to various Medicare Administrative Contractors (MACs), reviews information upon receipt, and incorporates findings into investigation file
- Generates ASR alerts from Fraud Prevention System (FPS) to UCM
- Prepares, requests, and tracks vetting of leads for investigation from external stakeholders (e.g. CMS, law enforcement, states)
- Provides reporting to external stakeholders, as appropriate
- Identifies opportunities to improve processes and procedures
- Has the responsibility and authority to perform their job and provide customer satisfaction.
Required Skills
To perform the job successfully, an individual should demonstrate the following competencies:
- Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.
- Problem Solving - Gathers and analyses information skillfully; Identifies and resolves problems.
- Written Communication - Writes clearly and informatively; Able to read and interpret written information.
- Judgment - Supports and explains reasoning for decisions.
- Ability to work independently with minimal supervision.
- Ability to communicate effectively with all members of the team to which he/she is assigned.
- Ability to grasp and adapt to changes in procedure and process.
- Ability to effectively resolve complex issues.
Required Experience
Education and/or Experience:
Required:
- An Associate's Degree or two years' experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions or equivalent combination of education and experience.
Preferred:
- Experience in healthcare programs or fraud investigation/detection;
- Experience in a federal or state healthcare programs
- Experience in a related field that demonstrates expertise in reviewing, analyzing, and making appropriate decisions.
- Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator
Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.
Salary Range
$22.75 - $29.56 |
Qlarant
$22.75 - $29.56
Apr 23, 2025