Job Summary Under limited supervision, this position is responsible for developing and maintaining an anti‑fraud program which includes the development and delivery of training, filing fraud plans, and reports. It also involves reviewing organizational or functional activities related to alleged fraud, waste, and abuse perpetrated by providers, members, facilities, pharmacies, groups, and/or employees of the organization and its subsidiaries. The incumbent conducts interviews, performs field investigative work, prepares cases for referral to federal, state, and local law‑enforcement entities, testifies in court, and coordinates the recovery of misappropriated funds. Additionally, the role conducts audits to comply with internal audit and regulatory requirements. About Maryland Care Management, Inc. (MCMI) Maryland Care Management, Inc. (MCMI) manages Maryland Physician Care’s statewide provider network of hospitals and physicians. Since 1996, Maryland Physicians Care has served the HealthChoice Medicaid population, reaching over 230,000 members and representing one of Maryland’s largest Medicaid‑managed care organizations. Why Join Us MCMI offers flexible work arrangements, competitive salary, and comprehensive benefits including medical, dental, vision, 100% employer Term Life Insurance, Short and Long‑Term Disability, 401(k) Employer Match up to 4%, 20 days of PTO, tuition assistance, and professional development. Our culture values diversity, equity, and inclusion, with ongoing initiatives to support all employees and members. What You’ll Do Develop and maintain an annual anti‑fraud program, facilitate fraud training, and file annual fraud plans and reports in accordance with state regulations. Conduct reviews of programs as requested, identify involved parties by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees. Interview providers, members, or other individuals necessary to complete a case review or special project. Determine the scope of allegations or special projects by assembling information, statistics, policies, procedures, licensure data, and contracts. Coordinate data extracts by assessing multiple internal and external databases. Take action to prevent further improper payments, forwarding cases to the Compliance Committee and/or law enforcement and regulatory agencies; provide support as needed. Complete all necessary field investigative work for resolution of alleged fraud, waste, and abuse cases. Recover misappropriated funds and work with Finance to ensure proper financial statement recording. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements. Perform other duties as assigned. Secondary Functions Assist the Chief Compliance & Government Relations Officer with special projects to meet corporate, departmental, and health‑plan goals. Research and complete correspondence to State regulatory agencies as required by management agreements and/or private review agent and third‑party administrator licensures. Knowledge and Skills Knowledge of provider facility payment methodology, claims processing systems, and coding and billing proficiency. Knowledge of HMO, managed care, Medicaid managed care, and/or Medicare managed care working environments. Knowledge of technical and financial aspects of the health‑insurance industry. Strong computer skills required to design reports and audit tools, and to use fraud/abuse data‑mining tools. Education and Work Experience High school diploma/GED required. Preferred Bachelor of Science or Arts degree in a health‑related field. Three (3) to five (5) years of relevant, progressive experience in legal, auditing, or operational management (claims, finance, reimbursement, or contracting), preferably within a managed care/Medicaid‑Medicare environment. EEOC Statement Following applicable federal, state, and local laws, MCMI prohibits discrimination in employment based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, or any other characteristic protected by law. This commitment extends to all aspects of employment, including hiring, promotion, compensation, benefits, training, social and recreational programs, and all other conditions and privileges of employment. As a healthcare organization, we recognize the vital importance of inclusivity in delivering quality care to our patients and foster an environment where all individuals feel respected, valued, and supported. Salary 80‑88k #J-18808-Ljbffr Maryland Physicians Care
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