Medical Claims Fraud Investigator

Overview

Main Purpose of Job
The primary purpose of this position is to:A. Perform data mining and analyze Medicaid claims to identify billing irregularities and identify provider billing outliers in an effort to identify bad providers and reduce fraud, waste and abuse against the Maryland Medicaid Program.
B. Plan and conduct reviews of Medicaid provider billings with emphasis on medical coding investigations, searching for overbilling by using highest reimbursement codes (upcoding), unbundling of medical procedure codes, and billings using medical codes that don’t match type of provider or type of services rendered.
C. Plan and conduct investigations of Medicaid providers to include reviewing their claims universe, selecting audit samples, identifying risks, developing audit workplans, planning and executing onsite provider visits to interview billing staff, collect and scan documents, executing audit steps, developing audit findings and writing audit reports to include findings and recommendations.
D. Ensure provider billings are in compliance with COMARs and other State and Federal regulations. This position will utilize specialized medical coding knowledge, certifications and extensive experience in Current Procedural Terminology coding (CPT), Internal Classification of Disease coding (ICD-10), and Healthcare Common Procedure Coding (HCPCS), coding conventions, as well as general billing experience.
MINIMUM QUALIFICATIONS
Education:   Graduation from an accredited high school or possession of a high school equivalency certificate.

Experience: Five years of administrative staff or professional work.

Notes:

1. Candidates may substitute 30 credit hours from an accredited college or university for each year up to four years of the required experience.

2. Candidates may substitute the possession of a Bachelor’s degree from an accredited college or university and one year of experience in administrative staff or professional work for the required experience.

3. Candidates may substitute the possession of a Master’s degree from an accredited college or university for the required experience.

4. Candidates may substitute U.S. Armed Forces military service experience as a commissioned officer involving staff work related to the administration of rules, regulations, policy, procedures and processes, or overseeing or coordinating unit operations or functioning as a staff assistant to a higher ranking commissioned officer on a year-for- year basis for the required experience.
DESIRED OR PREFERRED QUALIFICATIONS
The desired candidate should possess the following:Experience with data mining for irregularities in medical coding by medical providers.
Experience investigating medical coding irregularities in medical billings.
Experience reviewing medical records and ensuring documentation supports the medical coding.
Certified Professional Coder certification/designation.
Experience with medical billing coding, including: HCPCS, ICD-10, CPT.
Experience in applying and interpreting medical coding.
Experience analyzing medical codes to detect incorrect usage of medical codes and identify fraudulent upcoding.
LICENSES, REGISTRATIONS AND CERTIFICATIONS
Employees in this classification may be assigned duties which require the operation of a motor vehicle. Employees assigned such duties will be required to possess a motor vehicle operator’s license valid in the State of Maryland.
SELECTION PROCESS
Applicants who meet the minimum (and selective) qualifications will be included in further evaluation. The evaluation may be a rating of your application based on your education, training and experience as they relate to the requirements of the position. Therefore, it is essential that you provide complete and accurate information on your application. Please report all related education, experience, dates and hours of work. Clearly indicate your college degree and major on your application, if applicable. For education obtained outside the U.S., any job offer will be contingent on the candidate providing an evaluation for equivalency by a foreign credential evaluation service prior to starting employment (and may be requested prior to interview).

Complete applications must be submitted by the closing date. Information submitted after this date will not be added.

Incorrect application forms will not be accepted. Resumes will not be accepted in lieu of a completed application.

Candidates may remain on the certified eligible list for a period of at least one year. The resulting certified eligible list for this recruitment may be used for similar positions in this or other State agencies.