Qlarant

Title: NCI Surveyor Location: SD Home Based, Remote, SD, US Job Description: Best People, Best Solutions, Best Results Qlarant is seeking detail-oriented, professional Surveyors for this role to conduct National Core Indicators (NCI) surveys with people receiving services through South Dakota’s HCBS waivers. These Surveyors should be located in or near Sioux Falls, Rapid City, Pierre, Aberdeen or Brookings/Huron South Dakota. Surveyors will be responsible for conducting both NCI- Intellectual and Developmental Disabilities (NCI-IDD) and NCI- Aging and Disabilities (NCI-AD). Surveyors play a key role in gathering person-centered data that support statewide quality improvement and helps support the state of South Dakota in understanding from the personal perspective if services meet the needs, preferences, and experiences of participants. Responsibilities - Conduct in-person, telephonic, and virtual NCI surveys with people using HCBS services in South Dakota. - Follow all NCI and Qlarant protocols to ensure accuracy, consistency, and confidentiality. - Schedule and complete assigned surveys within designated timeframes. - Engage respectfully with participants, using active listening, and clear communication - Document responses accurately and enter data into the required electronic survey platform. - Maintain participant privacy and comply with HIPAA and all applicable state and federal requirements. - Report any concerns, inconsistencies, or required follow‑ups to the Qlarant project team. - Attend required training sessions and quality assurance meetings. - Travel within assigned regions of South Dakota as needed. Qualifications - Bachelor degree with at least one year of experience working with older adults or people with disabilities or, Associate degree with at least two years experience working with older adults or people with disabilities - Experience working with older adults and people with disabilities including intellectual or developmental disabilities. - Strong interpersonal communication skills and the ability to build rapport with diverse individuals. - High attention to detail and commitment to data accuracy. - Ability to work independently, manage schedules, and meet deadlines. - Reliable transportation for conducting in‑person surveys across the state (as applicable). - Comfortable using laptops to record survey responses. - Surveyors will be required to submit to background screening. - Surveyors must live in or around the following cities: Sioux Falls, Rapid City, Pierre, Aberdeen, Brookings/Huron Working Conditions - Field‑based role with travel within South Dakota (as applicable). - Flexible hours based on survey scheduling and participant availability. - May involve interviewing people at home, community settings, provider locations, or in a virtual or other remote environment.

• Facilitates routine evaluations to assess the extent to which individuals with intellectual developmental disabilities (IDD) are receiving customized support and services • Performs scheduled reviews to assess effectiveness of IDD service providers • Assists management in identifying areas for improvement in service delivery • Analyzes data related to program outcomes and client satisfaction

Role Description Owns responsibility for ensuring the optimal performance of the medical review division, continuously monitoring and analyzing performance metrics to identify opportunities for improving processes and procedures. Assists and supports Director – Medical Operations in operations and administration of contracts, overseeing the day-to-day activities of clinical teams. Communicates regularly and serves as a liaison with government agencies, regulatory bodies, and other external stakeholders to ensure transparent and compliant company programs. - Supervises teams to monitor and ensure compliance with relevant laws, regulations, and organizational policies. - Collaborates inter-departmentally to prioritize compliance efforts and address regulatory requirements. - Implements measures to mitigate potential risks to program integrity. - Ensures best practices are followed to maintain and enhance the quality of nursing activities, ensuring they meet established standards and guidelines. - Engages with governmental and law enforcement stakeholders as required. - Acts independently to assess existing nursing processes for efficiency, effectiveness, and compliance. - Collaborates with other departments, stakeholders, and external entities to ensure a comprehensive approach to program integrity and patient care. - Works closely with the Supervisor - Clinical Review’s staff to manage workload, ensuring timeliness and quality of service delivery. - Maintains accurate documentation of nursing program activities and produces regular reports on metrics related to program integrity, compliance status, and quality. - Instructs nursing staff on compliance and integrity matters, ensuring they understand and adhere to policies and procedures. Provides job-specific orientation and training as needed. - Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development. Provides job specific orientation and training when called upon. Qualifications - Minimum Bachelor's Degree required Requirements - 5 - 7 years of experience required; 8 - 11 years preferred - Current, active and non-restricted RN licensure required - Coding certification preferred Company Description 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.

Role Description Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims. - Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse. - Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud. - Consults with benefit integrity investigation experts and pharmacists for advice and clarification. - Completes case summaries and provides results to investigators to support the investigative process. - Provides case specific or plan specific data entry and reporting. - Participates in internal and external focus groups, as required. - Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations. - Testifies at various legal proceedings, as necessary. - Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions. Qualifications - Minimum Bachelor's Degree required (can be substituted for experience). - 2 - 4 years of experience required; 5 - 7 years preferred. - Medical Review or Utilization Management experience preferred. - Medicare/Medicaid experience preferred. Requirements - Current, active and non-restricted RN licensure required. - Coding certification preferred. Benefits - 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.

• Works with a team of internal and external professionals as a subject matter expert • Participates in planning and execution of team projects, assisting with setting strategic goals • Implements processes and uses necessary tools to enhance project execution and drive consistent performance improvements • Conducts research of program areas/topics defined by management; participates in internal and external focus groups • Utilizes experience to identify appropriate reports, rules, and regulations for drafting vulnerability reports • Meets regularly with teams to discuss current and future projects; advises teams and management • Contributes to final written product presented to stakeholders; proofreads written products of team members • Serves as a productive member of external and internal teams to ensure all deadlines for deliverables are met • Briefs management on projects, including completion timelines and potential difficulties • Provides clinical input as a Subject Matter Expert for program integrity and program vulnerability • Identifies and mitigates risks proactively, implementing strategies to ensure continuity of project execution • Participates in project reporting and performance analysis, ensuring accuracy of project data

Role Description Leads advanced analytics initiatives that transform complex data into strategic insights and measurable business impact. Oversees the design and execution of predictive modeling, machine learning, and statistical studies that forecast outcomes, inform decisions, and drive operational excellence. Applies deep technical expertise in tools such as SAS, SQL, R, Python, and Tableau to identify trends, variances, and opportunities for improvement, ensuring analyses are clear, actionable, and aligned with organizational priorities. Partners with senior leadership and research teams to uphold scientific rigor in study design, data validity, and methodological integrity, establishing scalable analytic practices that strengthen quality, efficiency, and innovation across the enterprise. Essential Functions - Leads the design and implementation of advanced data analysis strategies, including statistically sound sampling methodologies, predictive modeling, and trend analysis to identify opportunities, variances, and outliers that drive quality improvement and focused investigations. - Develops and applies epidemiologically sound indicators and benchmarks to assess performance and quality of care, ensuring analyses align with established standards and comparative frameworks. - Mentors junior data analysts and scientists in advanced methodologies, coding practices, and statistical interpretation, fostering technical growth and methodological rigor across the team. - Designs and implements high-performance algorithms and machine learning models within distributed computing environments, ensuring scalability, efficiency, and scientific accuracy. - Drives the development of innovative data science solutions and formulates strategic data initiatives that align with organizational objectives and competitive priorities. - Applies deep domain expertise and advanced modeling techniques to integrate complex data from diverse sources, producing actionable insights and solutions for high-impact business and healthcare challenges. - Leads research and innovation initiatives within the data science community, contributing to open-source projects, developing white papers, and promoting thought leadership through knowledge sharing and collaboration. - Develops and oversees the creation of technical reports, analytic studies, and quality improvement publications, ensuring accuracy, clarity, and defensibility of methodologies and results. - Designs and evaluates intervention strategies and re-measurement methodologies to assess the impact of quality improvement initiatives, translating data findings into practical recommendations. - Collaborates with cross-functional leaders to communicate complex data science results in a clear, actionable manner, aligning analytical outcomes with strategic decision-making and long-term organizational goals. Qualifications - Bachelor's Degree required; Master's Degree in Statistics preferred. Requirements - 8 - 11 years required; 12 - 14 years preferred. Benefits - 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.

• Ensures the integrity and accuracy of claims processes and protocols. • Collects data for audits/investigations into claims, utilizing analytical skills and attention to detail. • Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. • Adheres to industry regulations and policies for managerial follow-up. • Analyzes data to assess the validity of claims. • Provides accurate recommendations to management for claim resolution and closure. • Documents and inputs all findings while preparing comprehensive reports that may be used for legal or audit/investigative purposes.

Role Description Oversees audits/investigations and audit/investigation workload. Performs in-depth evaluation and makes field level judgments related to audits/investigations of potential Medicare fraud waste and abuse audits/investigations or cases compliance cases (e.g. Medicare and/or Medicaid) that meet established criteria for referral to the appropriate agency(ies) for administrative action or to law enforcement for criminal action. Essential Functions - Reviews new audits/investigations and/or incoming leads to determine appropriateness and assigns to auditors/investigators; vets providers as required with appropriate agency(ies) and law enforcement; supervises vetting process. - Reviews audit/investigation plans and priorities to ensure appropriateness and quality for the specific functions/workload assigned to team. - Conducts file reviews regularly of audits/investigations to ensure audit/investigation plan is appropriate and the audit/investigation file documents are entered and summarized within the case tracking systems appropriately. - Reviews auditor/investigator requests for information, data, reports, and correspondence to ensure quality and appropriateness. - Supervises and conducts audit/investigation actions such as interviewing, onsite audit/investigation, and/or site verification as needed. - Leads audit/investigation projects including developing an audit/investigation strategy, conducting meetings with stakeholders, reviewing project actions for quality, and documenting findings in reports for management. - Communicates with the Data and Medical Review departments to ensure efficient audits/investigations. - Prepares and presents audits/investigations, overpayments, and questions for stakeholder meetings. - Documents audit/investigation information and file reviews (interviews, events, findings, communications, etc.) into the case tracking systems and updates systems as needed. - Determines audit/investigation appropriateness of fraud, waste, and abuse issues in accordance with pre-established criteria. - Reviews audit/investigative findings with auditors/investigators and approves course of action. - Supervises and prepares team’s audits/investigations for the Major Case Coordination meetings and reviews for quality assurance. - Initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting audit/investigation findings for their consideration to further audit/investigate, prosecute, or seek other appropriate regulatory or administrative remedies. - Supervises administrative remedies in accordance with major case coordination direction (e.g. payment suspensions, revocations, provider education) and reviews for quality assurance. - Reviews and approves closing summary of audit/investigation. - Collects information and documentation as requested by internal and external stakeholders (e.g. CMS, law enforcement, FOIA requests) and submits, as required. - Collaborates with other program integrity contractors, as needed. - Testifies at various legal or administrative proceedings, as necessary. - Manages team performance through regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development. Qualifications - Minimum Bachelor's Degree required Requirements - 5 - 7 years of experience required; 8 - 11 years preferred - Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator Certification preferred Company Description 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.

• Develops actionable insights to help identify, understand, and resolve moderately complex business problems • Leverages big data and innovative problem-solving techniques to forecast future trends and outcomes based on past data patterns • Works individually, as well as with higher-level data scientists, designing experiments to solve problems with code and building predictive models and machine learning algorithms tailored to solve intricate business challenges • Develops an in-depth understanding of the business's needs and objectives, enabling the identification and formulation of pertinent questions that can be effectively addressed through data analysis • Applies deep learning algorithms and models for tasks such as image recognition, natural language processing, and other complex patterns • Applies highly developed knowledge when applying advanced statistical methods to analyze complex datasets, uncovering nuanced insights and relationships • Acts as a top-level specialist, optimizing machine learning models for efficiency, scalability, and improved performance in real-world applications • Develops strategy for expertly selecting and engineering features to enhance model interpretability, accuracy, and generalization • Designs and conducts A/B tests and experimentation to evaluate the impact of changes and interventions • Leads cross-functional collaboration efforts, working closely with diverse teams to integrate data science solutions into business operations • Develops algorithms that can scale to handle large datasets and complex computations, ensuring efficiency in processing • Implements systems to deploy machine learning models into production environments, enabling their integration into operational systems • Develops automated data pipelines for efficient data collection, processing, and integration, streamlining the end-to-end data science workflow

• Monitors the processing and reconciliation of incoming electronic medical records • Supports research of prepay and post-pay record questions as well as research and return of misdirected documents • Provides first level review for changes and supports problem-solving solutions for system issues • Provides expertise for implementing, deactivation, monitoring, quality assurance, and reporting of prepay edits • Facilitates meetings and coordinates presentations • Tracks and analyzes data and reports for prepay committee edit effectiveness • Creates templates and content for the external contractor annual fraud and abuse training