Mercy Health Healthcare Fraud Investigator - NC in Huntersville, North Carolina

Healthcare Fraud Investigator - NC

Job ID: 4653897

Updated: March 13, 2018

Geographic Location: HomeOffice

Location: Huntersville, NC, United States

Department: Legal

Full/Part Time: Full-Time

Shift: Days

Standard Hours: 40

Job Summary

Under the direct supervision of the Coding-Claims Audit Fraud Manager, this position contributes to the Ensemble and Mercy Health mission and vision by serving as the staff providing day-to-day claims compliance-fraud audits that align with the Ensemble revenue cycle-third party billing Corporate Responsibility Program (CRP) and the overarching efforts of Mercy Health Corporate Responsibility Program and Mercy Health’s independent internal audit contractor. Ensemble RMC LLC is a wholly owned subsidiary of Mercy Health and provides a wide-range of revenue cycle services to Mercy Health and non-Mercy Health clients. This position provides compliance program-related claims audit and fraud internal monitoring relative to Mercy Health and Ensemble operations conducted at local (Ohio) and remote locations (North Carolina) and supports compliance auditing requested by non-Mercy clients as part of contractual obligations.

Works collaboratively with the Mercy Health VP & Chief Corporate Responsibility Officer and the designated Ensemble Corporate Responsibility Officer (CRO) on performing internal compliance monitors and auditing which align with Mercy Health’s overall Corporate Responsibility Program and specific compliance responsibilities relative to Ensemble’s revenue cycle-third party billing services performed for Mercy Health as well as non-Mercy clients.

Assists the designated Coding-Claims Audit Fraud Manager in the review of Mercy Health and non-Mercy client coding, billing and claims processing policies and procedures for the development of compliance internal monitors and audit protocols and the prevention of fraud, waste and abuse. Identifies instances of non-compliance relative to policy and procedures.

Performs internal compliance monitors and claim audits specific to revenue cycle risk areas highlighted by the OIG Program Guidelines for Third Party Billing Companies, State Insurance Fraud; Managed Care or Governmental Value-Based payment programs and/or other enforcement agencies on behalf of Mercy Health and non-Mercy clients.

Qualifications - Minimum

Required Minimum Education: 4 year Bachelors Degree; Specialty/major: Healthcare Auditing, Health Information Management, Medical or Risk Management

Preferred Education: Graduate Degree Masters

Required: Coding and Auditing Experience, Certification in ICD-10 coding

Preferred: Experience with EPIC Electronic Medical Records System

Minimum five to seven years of in-depth experience within insurance claims industry or system healthcare operations, revenue cycle or coding/billing either from a consulting perspective or as an employee/manager.

Demonstrated working knowledge of Medicare and Medicaid, Insurance Managed Care including documentation, coding, reimbursement methodologies, as well as extensive familiarity with Department of Health and Human Services Office of Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS) rules, regulations and compliance guidance.

Excellent analytic and problem-solving skills to process auditing and monitoring reports, consultant studies and data compilations to discern opportunities, identify compliance risks and prioritize recommendations. Ability to take major strategic objectives and break them down into meaningful action steps.


Full-time hours, Day Shift

40 hours/week, 8:00am - 5:00pm

Position is based out of North Carolina - No remote option available.



Equal Employment Opportunity

It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.