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Fraud, Waste, and Abuse Investigator
2 months ago
Johns Hopkins Health Plans is a leader in provider-sponsored health plans. If you are interested in improving how healthcare is delivered, and have a passion to be at the forefront of change, JHHP is the place to call home. YOU belong here.
What awaits you:
- Work-life balance - Remote role
- Medical, Dental, and Vision Insurance.
- 403B Savings Plan w/employer contribution.
- Paid Time off & Paid holidays.
- Employee and Dependent Tuition assistance benefits.
- Health and wellness programs and MORE
Job Summary:
Under the direction of the Supervisor, FWA, this position has a two-fold function. First, using data analytic and fraud, waste and abuse software, the investigator conducts post-payment coding validation/reviews of claims to identify potential claims retractions. Skills involved include, but are not limited to knowledge of medical coding, diagnoses codes, multiple claims systems, provider/member claims history, knowledge of plan benefits, claims guidelines, contact with healthcare providers, and initiating claims adjustments. The investigator works with the Supervisor, FWA to establish consistent Service Level Agreement goals to achieve the overall production goals. Second, this position works independently or part of an assigned team that may include Compliance Auditors to develop and execute FWA investigations and/or audits of providers. Duties include reviewing claims systems data and reports, researching provider and/or member claims activity and history, conducting medical record reviews, contacting members and providers when appropriate, analysis of provider contracts and other documents to identify potential fraud, waste and abuse. Investigators are responsible for preparing documentation to substantiate findings including preparing and submitting spreadsheets, reports, audit findings letters, and other documentation and to ensure investigations and audits are timely, effective, and achieve the overall goals of the department. Timely maintenance and updates to the case file documentation, departmental case tracking system, and preservation of discoverable reports and documents is required. Providing support and/or responses to external agencies and may include the Maryland Department of Health, Medicaid Fraud Control Units, Office of the Inspector General, and other state and/or federal agencies. This position is also responsible for recommendations to the Supervisor, FWA regarding improvements and corrections.
Education:
Associate's Degree in Business or Health Administration is required. Equivalent experience may be substituted for a degree where appropriate. Bachelor’s Degree is preferred.
Skills:
Requires the ability to read, abstract, and understand a patient medical record as it relates to clinical documentation and diagnostic/procedural coding of the services provided.
Requires the ability to identify, through investigation and analysis, underlying causes and contributing factors to areas of weakness and problems identified.
Requires the ability to develop and perform follow-up audits/monitoring related to the investigation and the ability to evaluate the implementation of corrective actions.
Requires a professional level of knowledge of ICD9CM, ICD10 CM and PCS, CPT and HCPCS coding terminology.
Requires knowledge of insurance claim filing and billing principles including CMS-1500 and UB04 claims forms and required billing conventions. Familiarity with the Maryland Health Services Cost Review Commission (HSCRC) regulatory requirements is preferred.
Must possess strong computer skills in standard PC word processing, spreadsheet and database applications (such as those found in the Microsoft Office Suite).
Who we are:
Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine. JHHP is a $3B business serving over 500,000 active members with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHP is a leader in provider-sponsored health plans and is poised for future growth.
Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, we are setting the pace for change within the healthcare industry. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for our members and the communities we serve.
Johns Hopkins Health System and its affiliates are drug-free workplace employers.
