Meridian

  • Fraud, Waste and Abuse Investigator

    Job Location US-MI-Detroit
    Job ID
    2018-6558
    Category
    Legal/Compliance
    Business Line
    CMC Corporate
  • Overview

    Who we are:

     

    Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.

     

    We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.

     

    Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.

    Responsibilities

    • Participate in the detection, investigation and ongoing monitoring of member and/or provider Fraud, Waste and Abuse through random audits, data analysis, medical record review and onsite and desk audits
    • Provide recommended action based on investigative summary
    • Proactively apply knowledge of current FWA Schemes, coding guidelines and medical policies to identify areas of risk for Fraud, Waste or Abuse
    • Prioritize leads from external sources
    • Stay current on published fraud cases
    • Interview members and/or providers regarding the Fraud, Waste and Abuse in question
    • Appropriately utilize the database to track and trend provider and member inquiries, concerns, complaints, and appeals as they relate to Fraud, Waste and Abuse and maintain complete case files
    • Package Fraud, Waste and Abuse referrals to appropriate law enforcement and/or regulatory agencies
    • Develop and administer provider education programs focusing on Fraud, Waste and Abuse best practices
    • Develop internal fraud awareness training programs and consult Fraud, Waste and Abuse policies and procedures
    • Participate in appropriate State Medicaid/Medicare task force meetings
    • Assist in auditing and investigating EOB claims that are referred for fraud, waste and abuse for each state MHP is operating in and report the results to the Compliance Officer and the appropriate states FWA committee
    • Review ER and Pharmacy history reports on members for possible abuse/non compliance
    • Perform other duties as assigned

    Qualifications

    What you can bring to Meridian:

    • Bachelor’s degree is required
    • Master’s degree is preferred
    • Strong interest in Medicare and Medicaid Fraud, Waste and Abuse investigation
    • Other certifications a plus: Certified Coding Specialist (CCS), Certified Fraud Specialist (CFS), Accredited Healthcare Fraud Investigator (AHFI) and Certified Fraud Examiner (CFE)
    • At least one year experience working in a Managed Care Organization
    • Minimum of 2 years’ experience working on Healthcare Fraud Investigations
    • Experience investigating Medicaid and Medicare Fraud, Waste and Abuse a plus
    • Computer proficiency in a Windows environment, including MS Office Suite
    • Healthcare claims adjudication experience helpful
    • Knowledge of Managed Care and the Medicaid and Medicare program is required
    • Knowledge of National Committee for Quality Assurance (NCQA), URAC or general accreditation standards
    • Working knowledge of Medicaid and Medicare a must
    • Analytical and problem solving skills
    • Strong written and verbal communication skills
    • Strong listening and observation skills
    • Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner
    • Attention to detail and high level of accuracy
    • Works independently; collaborates well with peers and customers
    • Demonstrated organizational and prioritization skills with ability to manage multiple priorities effectively

    What Meridian can offer you:

     

    • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • Meridian offers 401k matching that is above the national average.
    • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
    • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.

     

    Equal Opportunity Employer 

     

    #MSTR

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