Auditor/Investigator I

About the Company

Qlarant is a nonprofit organization that works with public and private partners to improve the quality, safety, and efficiency of health care and human services delivery. Its work spans population health, utilization review, quality review for managed care organizations, and quality assurance for programs that support people with developmental disabilities. The organization also plays a national role in detecting and preventing fraud, waste, and abuse for large enterprises. Through its Foundation, Qlarant also offers grants for initiatives that serve underserved communities.

Best People, Best Solutions, Best Results

Job Summary

This is an entry-level professional role focused on building a solid foundation for protecting the accuracy and integrity of claims processing. The position involves collecting information for audits and investigations, examining supporting documents, interviewing relevant individuals, and coordinating with stakeholders to gather facts needed to close cases successfully. The role also requires identifying patterns or discrepancies that may indicate fraud, waste, or abuse, following company policies and industry regulations, evaluating claims data, and preparing clear recommendations for management. All findings must be documented accurately and compiled into detailed reports that may support legal or investigative use.

Key Responsibilities

• Carry out routine, neutral reviews and investigations of customer claims to determine whether they are valid and handled fairly.
• Respond to customer questions and concerns, and escalate cases when additional review is required.
• Maintain thorough and well-organized records of findings, ensuring accuracy and compliance with legal and regulatory standards.
• Use job-related knowledge to help design and apply methods that detect and deter fraudulent activity in claims handling.
• Interview witnesses, claimants, and other involved parties to gather additional context and supporting information.
• Work with internal teams to ensure audits and investigations are processed correctly and in line with legal and regulatory requirements.
• Enter audit and investigation records into the database promptly and accurately.
• Communicate case findings clearly and professionally to customers, claimants, and other stakeholders while managing expectations and providing updates.
• Assist management with routine audit and investigation activities while following all applicable regional and federal standards, regulations, and procedures.

Supervision

Works under general supervision, handles standard assignments independently, and refers uncertain or questionable matters to a manager.

Education and Experience

A bachelor’s degree is required. Education may be considered in place of experience, and experience may also be considered in place of education. The role calls for 0 to 2 years of experience, with 2 to 4 years preferred.

Preferred Certifications

Preferred credentials include Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator.

Additional Conditions

Qlarant is committed to equal employment opportunity for minorities, women, protected veterans, and individuals with disabilities.

The workplace is drug-free, and every offer depends on successful completion of pre-employment background and drug screening.