Who we are:
Meridian is a family-owned, family-operated company 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 three different states (Michigan, Illinois, and Ohio).
Our employees work hard, play hard, and give back. Meridian employees enjoy: Happy hours, special events, company sports teams, potlucks, Bagel Fridays, weekly Executive Lunches, and volunteer opportunities.
- Participate in the detection, investigation and ongoing monitoring of member, provider and/or pharmacy Fraud, Waste and Abuse through random audits, data analysis, record review and onsite and desk audits
- Provide recommended action based on investigative summary
- Proactively apply knowledge of current FWA Schemes, coding guidelines and medical policies to identify areas of risk for Fraud, Waste or Abuse
- Prioritize leads from external sources
- Stay current on published fraud cases
- Interview members and/or providers regarding the Fraud, Waste and Abuse in question
- Appropriately utilize the database to track and trend pharmacy, provider and member inquiries, concerns, complaints, and appeals as they relate to Fraud, Waste and Abuse and maintain complete case files
- Package Fraud, Waste and Abuse referrals to appropriate law enforcement and/or regulatory agencies
- Develop and administer education programs focusing on Fraud, Waste and Abuse best practices
- Develop internal fraud awareness training programs and consult Fraud, Waste and Abuse policies and procedures
- Participate in appropriate State Medicaid/Medicare task force meetings
- Assist in auditing and investigating EOB claims that are referred for fraud, waste and abuse for each state MHP is operating in and report the results to the Compliance Officer and the appropriate states FWA committee
- Review ER and Pharmacy history reports on members for possible abuse/non compliance
What you can bring to Meridian:
- Bachelor’s degree is required
- Master’s degree is preferred
- Strong interest in Pharmacy, Medicare and Medicaid Fraud, Waste and Abuse investigation
- Other certifications a plus: Certified Pharmacy Technician (CPhT), Certified Fraud Specialist (CFS), Accredited Healthcare Fraud Investigator (AHFI) and Certified Fraud Examiner (CFE)
- At least one year experience working in a Managed Care Organization or Pharmacy
- Minimum of 2 years’ experience working on Healthcare Fraud Investigations
- Experience investigating Pharmacy, Medicaid and Medicare Fraud, Waste and Abuse a plus
- Retail pharmacy experience a plus
What Meridian can offer you:
- Our healthcare benefits include a variety of PPO 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