• Fraud, Waste and Abuse Coding Auditor

    Job Location US-MI-Detroit
    Job ID
    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.


    A Day in the Life of a Fraud, Waste and Abuse Coding Auditor:


    This position will be extracting information from Evaluation and Management medical records for accuracy and proper assignment of CPT-4, ICD-9, and HCPCS codes for the Fraud Waste and Abuse section of the Compliance Division. Additionally duties, such as procedural coding review, use of modifiers 25 and 59, data mining, and establishing a proactive culture of compliance will be provided as needed.


    • Demonstrates thorough knowledge of Medicare/Medicaid, ICD-9, CPT-4, and NCCI Guidelines. Utilizes other reputable resources (CPT® Assistant, industry associations and organizations) in audit determinations
    • Audits clinical documentation and information contained in the MCS Claims system against the medical records, claims and other documentation submitted by the provider and identify coding errors, inconsistencies, anomalies, abnormal billing patterns and other indicators (e.g. services not rendered, up-coding, un-bundling, etc.) of suspected fraud and abuse.
    • Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse
    • Coordinate with fraud, waste and abuse team members to develop recommendations regarding the appropriateness of diagnosis and procedure codes submitted by the provider and identify any overpayment recovery due to those errors
    • Researches insurance questions about codes and charges
    • Serve as a coding resource for the Compliance Division
    • Attend meetings as necessary to provide information relating to coding and compliance.
    • Provide related weekly, monthly and year end reports of audit findings to fraud, waste and abuse team
    • Assist providers in obtaining and maintaining a 5% or less financial error rate through educational communications and/or sessions
    • Develop a proactive coding culture utilizing the OIG annual work plan as a template
    • Perform other duties as assigned


    What you can bring to Meridian:

    • High School Diploma is required
    • Successful completion of medical terminology course is preferred
    • Previous Medicare coding, auditing, billing or claims payment experience is preferred
    • Active RHIT/RHIA certification with 2-5 years’ experience in a related field is preferred
    • Active CPMA and/or CCS-P accreditation with 2-5 years’ experience in coding quality is preferred
    • Active CPC and/or CCS accreditation with 2-5 years’ experience in Evaluation and Management coding quality with a commitment to specialization in auditing is preferred
    • Knowledge of managed care and government programs is preferred
    • Knowledge of the health insurance industry is preferred
    • Microsoft Office and Medical Billing Software Applications experience required
    • Willingness to work in a fast-paced, team oriented environment while maintaining a constant focus on quality improvement and opportunities
    • Ability to demonstrate adaptability and flexibility to changes and respond to new ideas and approaches is required
    • Ability to learn new skills and acquire knowledge independently and in the team setting

    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


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