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Job Details

Compliance Investigator

Requisition #: 182273
Location: Johns Hopkins Health Care, Hanover, MD 21076
Category: Non-Clinical Professional
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: July 19, 2019

Johns Hopkins Health System employs more than 20,000 people annually. Upon joining Johns Hopkins Health System, you become part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. If you share in our vision, mission and values and also have exceptional customer service and technical skills, we invite you to join those who are leaders and innovators in the healthcare field.

Under the direct supervision of the Manager of Special Investigations, Audits and Ongoing Monitoring, the Compliance Investigator is responsible for: fraud and abuse investigations and working in tandem with the Department’s Compliance Auditors in performing non-medical necessity portion of audits. By definition the non-medical necessity portion of the audit is that section which does not require licensed clinical expertise. Examples of non-medical necessity audits are those that assess proper use, assignment, and reimbursement of diagnosis and procedural codes as well as audits to assess contractual and regulatory compliance.

The Investigator is responsible for:

  • Working in tandem with assigned auditor in performing departmental audits
  • Summarizing his or her audit findings
  • Reporting such findings to his or her Manager, Assistant Director and Director of Corporate Compliance and ultimately to the Compliance Oversight Committee
  • Making recommendations to the Manager, Assistant Director and Director of Corporate Compliance for improvement and correction where identified.
  • Developing with assigned auditor relevant and individualized audit corrective action and educational plans of action

The Investigator is also responsible for responding to and investigating allegations of member and provider fraud. He or she identifies compliance risk areas and assists with the development and implementation of policies and corrective action plans where indicated.


  1. Research suspicious claims activities
  2. Develop subject matter specific audit/investigation tool
  3. Conduct investigations/audits of suspect claims
  4. Conducts site visits as warranted
  5. Participate in recovery of wrongful payment to providers
  6. Articulate findings to Senior JHHC Management, appropriate Departmental personnel and other internal customers.
  7. Coordinating and tracking Compliance Department initiated corrected actions where necessary
  8. Assist with the drafting and/or updating of JHHC Compliance related policies and procedures
  9. Develop individualized and network provider education


  • Associate Degree in Business or Health Administration is required; Equivalent experience may be substituted for a degree where appropriate; Bachelor’s Degree is preferred
  • 5 years health care experience
  • 3 years managed care, health insurance, hospital, physician practice, or other health care field
  • 3 years coding/claims auditing experience
  • 3 years claim system experience (MC400 and/or IDX strongly preferred)
  • 1 year of health care fraud auditing/investigation experience strongly preferred
  • Ability to read, abstract, and understand a patient medical record as it relates to clinical documentation and diagnostic/procedural coding of the services provided
  • Ability to identify through investigation and analysis underlying causes and contributing factors to areas of weakness and compliance problems identified
  • Ability to develop and perform follow-up compliance audits related to the investigation and the ability to evaluate the implementation of prescribed corrective actions
  • Professional level of knowledge in health care administration in general, especially as applied to Medicaid managed care plans; Must understand current health care regulatory requirements
  • Professional level of knowledge of ICD9CM, ICD10, CPT and HCPCS coding terminology
  • Experience in health care fraud and abuse auditing
  • Knowledge of insurance claim filing and billing principles; Familiarity with the Maryland regulatory environment is preferred
  • Professional level of knowledge of medical, ICD9CM, CPT and HCPCS coding terminology
  • Must possess strong computer skills in standard PC word processing, spreadsheet and database applications (such as those found in the Microsoft Office Suite)
  • Knowledge of or experience using statistical audit software to identify and run reports showing negative trends in billing and documentation practices
  • Strong interpersonal, oral, and written communication skills; the ability to interact and communicate effectively with contracted providers, JHHC staff, and all levels of management is essential
  • Ability to research and understand compliance obligations of substantial complexity, including state and federal statutes and regulations; must possess the ability to convert compliance regulations into a logical and practical audit tool or scope document
  • Ability to plan and prioritize multiple tasks with minimal supervision
  • Strong analytical skills to effectively monitor billing, compliance, and related issues and report thereon
  • Strong writing skills are required to effectively communicate findings and recommendations to varied audience
  • Active Certified Professional Coder (CPC), Certified Professional Coder – Payer (CPC-P), Certified Professional Coder – Hospital (CPC-H), or Certified Coding Specialist Certification (CCS); In lieu of coding certification, must be able to sit for and successfully pass certification examination within 18 months of hire
  • Certified Fraud Examiner certification is preferred

Johns Hopkins Health System and its affiliates are Equal Opportunity/Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identity, sex, age, national origin, disability, protected veteran status, and or any other status protected by federal, state, or local law.


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