• Reviewing prescriptions to ensure accuracy • Sending prescriptions to the pharmacy to be processed • Reviewing EHR to ensure all necessary information is recorded • Reviewing lab order to ensure all lab orders are completed and recorded • Effective daily communication with contracted pharmacies • Swift and effective communication to correct any mistakes • Schedule Audits • Prescription Audits • Handle medication recalls appropriately • Ensuring payments are handled properly • Handling a high volume of charts

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Serves as an entry level professional who develops baseline plans for ensuring the integrity and accuracy of claims processes and protocols. Collects data for audits/investigations into claims, utilizing a combination of analytical skills and attention to detail, reviewing documentation, interviewing involved parties, and communicating with various stakeholders to gather relevant information for successful resolution and closure. Identifies opportunities to target fraud, waste, and abuse or discrepancies in claims submissions. Adheres to industry regulations and company policies for managerial follow-up. Analyzes data in order to effectively 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. Qualifications - Minimum Bachelor's Degree required Requirements - 0 - 2 years of experience required; 2 - 4 years preferred - Healthcare fraud experience required; Medicare experience preferred Benefits - Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities. Essential Functions - Conducts routine and impartial audits/investigations into customer claims, ensuring accurate and fair assessments of claims validity. - Provides customer service by addressing inquiries and concerns, and escalates audit/investigation, as needed. - Compiles detailed and organized records of audit/investigation findings, ensuring accuracy and compliance with legal and regulatory requirements. - Applies functional knowledge to create and implement strategies to identify and prevent fraudulent activities, safeguarding the integrity of the claims process. - Conducts interviews with relevant witnesses, claimants, and other stakeholders to gather additional information and perspectives on claims. - Communicates with appropriate internal teams to ensure the proper processing of audits/investigations, while adhering to legal and regulatory standards. - Ensures that all audit and investigative documents and records are processed into the database in a timely and accurate manner. - Communicates audit/investigation findings clearly and professionally to customers, claimants, and other stakeholders, managing expectations and providing updates. - Supports management in regular audit and investigation proceedings, ensuring full compliance with all applicable regional and federal standards, regulations, and protocols. Level of Supervision Received Under general supervision, proceeds alone on regular duties, referring questionable cases to manager. Certification(s) - Certified Fraud Examiner or Accredited Healthcare Anti-Fraud Investigator preferred

• Conduct audits in accordance with regulatory, contractual, and industry standards • Execute detailed claims audits using established methodologies, sampling frameworks, and documentation standards to ensure accuracy, consistency, and regulatory readiness • Communicate audit scope, expectations, and timelines clearly to delegated provider organizations throughout the audit lifecycle • Review and validate Corrective Action Plans (CAPs) submitted by delegated entities to ensure remediation fully addresses identified deficiencies

• Conduct credentialing audits in accordance with regulatory, contractual, and industry standards • Execute delegated credentialing audits using established methodologies, sampling criteria, and documentation standards to ensure accuracy, consistency, and regulatory readiness. • Evaluate delegated entities’ compliance with CMS, DMHC, NCQA, federal/state credentialing requirements, and Alignment’s contractual standards. • Maintain organized, complete, and audit-ready documentation to support regulatory reviews, accreditation audits, and internal oversight. • Ensure all audit activities align with the enterprise audit strategy set by the Manager, Audit Administration. • Engage delegated provider organizations to correct deficiencies and improve performance • Communicate audit scope, expectations, and timelines clearly to delegated provider organizations throughout the audit lifecycle. • Provide delegates with clear explanations of audit findings, including root causes, compliance gaps, and potential operational impacts. • Support delegated entities in understanding credentialing requirements and expectations for corrective actions. • Promote productive and professional working relationships to foster transparency, collaboration, and continuous improvement. • Perform risk assessment and prioritize audits • Assist in identifying high-risk focus areas by reviewing prior audit results, monitoring data, and operational issues related to credentialing performance. • Recommend audit prioritization based on risk severity, regulatory sensitivity, and emerging compliance trends. • Provide input to refine audit scopes and schedules in alignment with the Manager’s risk-based audit and monitoring strategy. • Escalate emerging risks or irregular credentialing issues to the Manager, Audit Administration for strategic review and inclusion in future audit planning. • Validate corrective actions for credentialing compliance • Review and validate Corrective Action Plans (CAPs) submitted by delegated entities, ensuring remediation fully addresses identified credentialing deficiencies. • Assess evidence such as updated credentialing files, process changes, workflow revisions, and policy updates to confirm compliance with regulatory and contractual standards. • Track CAP progress and ensure follow-up activities are completed and documented according to departmental requirements. • Escalate irregular, incomplete, or stalled CAPs to the Manager, Audit Administration to support timely issue resolution. • Report credentialing audit findings to facilitate organizational awareness • Prepare clear, concise, and well-structured audit summaries highlighting key risks, deficiencies, and improvement opportunities across delegated credentialing practices. • Contribute to department-standard reporting tools, dashboards, and audit documentation used for leadership and cross-functional communication. • Partner with Delegate Performance, Clinical Operations, Quality, Compliance, and other internal teams to ensure findings are understood and actionable. • Support preparation of materials for internal committees, regulatory bodies, and enterprise risk-management forums. • Manage multiple credentialing audits simultaneously, ensuring adherence to timelines, scope, and quality standards. • Monitor credentialing-related data to identify emerging trends, potential non-compliance, and areas requiring targeted review. • Contribute subject-matter insights during training or education sessions for delegated entities to reinforce credentialing expectations and reduce recurring deficiencies. • Support compilation of documentation and evidence for CMS, NCQA, or other regulatory audits. • Perform additional responsibilities and projects as assigned.