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MEDICAL CLAIMS FRAUD INVESTIGATOR (Administrator II)

Recruitment #25-002587-0013

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Introduction

GRADE

17

LOCATION OF POSITION

MDH Office of the Inspector General for Health
Program Integrity - Clinical Unit
201 W. Preston Street
Baltimore, MD 21201

Main Purpose of Job

The primary purpose of this position, which functions as a Medical Claims Fraud Investigator, 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:
  • Certified Professional Coder (CPC) certification
  • experience in medical billing and coding
  • experience/understanding of CPT, HCPCS, and ICD-10
  • experience auditing medical claims for irregular billing codes, including upcoding, unbundling, etc.
  • experience data mining claims data for aberrant coding trends to identify possible fraud, waste, and abuse
  • experience utilizing MS Excel at the intermediate level
The desired candidate should be detail oriented with excellent verbal and written communication skills and possess critical thinking and problem solving skills.

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.

BENEFITS

FURTHER INSTRUCTIONS

Online applications are highly recommended. However, if you are unable to apply online, the paper application (and supplemental questionnaire) may be submitted to MDH, Recruitment and Selection Division, 201 W. Preston St., Room 114-B, Baltimore, MD 21201. Paper application materials must be received by 5 pm, close of business, on the closing date for the recruitment, no postmarks will be accepted.

If additional information is required, the preferred method is to upload.  If you are unable to upload, please fax the requested information to 410-333-5689. Only additional materials that are required will be accepted for this recruitment. All additional information must be received by the closing date and time.

For questions regarding this recruitment, please contact the MDH Recruitment and Selection Division at 410-767-1251.

If you are having difficulty with your user account or have general questions about the online application system, please contact the MD Department of Budget and Management, Recruitment and Examination Division at 410-767-4850 or Application.Help@maryland.gov. 

Appropriate accommodations for individuals with disabilities are available upon request by calling: 410-767-1251 or MD TTY Relay Service 1-800-735-2258.

We thank our Veterans for their service to our country.

People with disabilities and bilingual candidates are encouraged to apply.

As an equal opportunity employer, Maryland is committed to recruitment, retaining and promoting employees who are reflective of the State's diversity.




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