Full-Time Fraud Det Analyst
Job Description
Summary/Position Objectives:
Under limited supervision, this position is responsible for developing and maintaining an anti-fraud program which includes the development and delivery of training and filing of fraud plans and reports. This position is responsible for conducting reviews of the organizational or functional activities related to alleged fraud, waste and abuse perpetrated by providers, members, facilities, pharmacies, groups and/or employees of the organization and subsidiaries. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. This position is also responsible for field investigative work necessary to complete a review of a special project, potential fraud, waste, and abuse case, conducting the initial reviews and coordinating the recovery of money related to fraud, waste, and abuse. The incumbent must be able to testify in a court of law, prepare cases for referral to various federal, state, and local law enforcement entities and work with those agencies through the closure of the case. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.
About Maryland Care Management, Inc. (MCMI)
Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care’s (MPC) statewide provider network of hospitals and physicians. Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD’s largest Medicaid-managed care organizations.
Why join us?
MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans.
Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members’ lives.
What You’ll Do:
Develop and maintain an annual anti-fraud program which includes facilitating fraud training and fraud awareness, as well as filing annual fraud plans and reports according to state regulations.
Conducts reviews of areas or programs as requested both internally and externally using department protocol. Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees.
Interviews providers, members, or any other individual(s) necessary to complete a case review or special project.
Determines the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctor’s agreements, contract, etc.
Coordinates data extracts by assessing multiple databases both internally and externally.
Take action to prevent further improper payments. Forwards cases to the Compliance Committee and/or law enforcement and regulatory agencies; provides support as needed.
Completes all necessary field investigative work for resolution or alleged fraud/waste and abuse cases.
Recover misappropriated funds paid by the organization and work with Finance to ensure proper recording of the financial statements.
Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.
Other duties as assigned.
Secondary Functions:
Assists Chief Compliance & Government Relations Officer (CCGRO) with special projects to meet corporate, departmental and health plan goals.
Researches and completes correspondence to State regulatory agencies as required by management agreements and/or private review agent and third-party administrator licensures.
Requirements
Knowledge and Skills:
Knowledge of provider facility payment methodology, claims processing systems and coding and billing proficiency.
Knowledge in HMO, managed care, Medicaid managed care and/or Medicare managed care working environments.
Knowledge of technical and financial aspects of the health insurance industry.
Strong computer skills are required to design reports and audit tools along with the ability to use fraud/abuse data-mining tools.
Education and Work Experience:
High school diploma/GED is required.
Preferred Bachelor of Science or Arts degree in health-related field.
Three (3) to five (5) years of relevant, progressive experience in the area of specialization: legal, auditing and/or operational (claims, finance, reimbursement or contracting) management experience, preferably within a managed care/Medicaid-Medicare working environment.
EEOC Statement:
Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment.
As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients. We strive to foster an environment where individuals of all backgrounds feel respected, valued, and supported. We aim to better comprehend the unique needs of our patients and provide healthcare services that are culturally competent and sensitive.
We encourage candidates from all backgrounds to apply and join us in our mission to provide compassionate and inclusive healthcare. We believe that a diverse workforce enriches our organization and allows us to better understand, connect with, and serve our diverse patient population.