Investigator

Job Title

Anti-Fraud Program Manager

Job Description

This job is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. The incumbent is responsible for conducting investigations of organizational or functional activities related to alleged fraud, waste and abuse perpetrated by providers, members, facilities, pharmacies, groups and/or employees of the organizations and Subsidiaries. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. The incumbent is also responsible for the field investigative work necessary to complete a review of a special project, potential fraud, waste and abuse case, conducting the initial investigations and coordinating the recovery/savings of money related to fraud, waste and abuse. The incumbent must be able to testify in a court of law, prepare cases for referral to various federal, state and local law enforcement entities and work with those agencies through closure of the case. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.

Essential Responsibilities

Performs investigations into potential and existing provider and member fraud, waste and abuse activities. Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries. Conducts interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project. Determines the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctors' agreements, contract, etc.

Develop and maintain annual anti-fraud program which includes facilitating fraud training and fraud awareness day, as well as filing annual fraud plans and reports according to state regulations. Responsible for updating annually the changes in insurance laws with regard to lines of business.

Coordinates data extracts by assessing multiple databases both internally and externally. Takes action to prevent further improper payments. Forwards case to the Credentialing and/or Medical Review Committee, law enforcement and regulatory agencies.

Responsible for completing all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.

Provides advisory support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.

Engages in delivery of audit results and overpayment negotiations. Responsible for recovery/ savings of misappropriated funds paid by Highmark and affiliated companies and work with Finance to ensure proper recording the financial statements.

Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements. Audits consist of contract, commissions, surveillance, workers' compensation and IME. In addition, this position will complete Office of Foreign Asset Control (OFAC) to ensure payments are not issued to unauthorized parties.

Other duties as assigned or requested.

Education

Required: Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field

Substitutions: 6 years of related and progressive experience in lieu of Bachelor's degree

Preferred: Master's Degree in Fraud, Forensics Accounting, Business or related field

Experience

Required: 3 years of relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations

Preferred: 1 year in Financial Analysis in an acute care hospital or health insurance setting

1 year in professional billing, facility Patient Financial Services, HIM, Internal Audit, Professional/Facility Reimbursement or Provider Contracting

Licenses or Certifications

Required: None

Preferred (any of the following): Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Accredited Healthcare Fraud Investigator (AHFI)

Skills

Must have knowledge of provider facility payment methodology, claims processing systems and coding and billing proficiency

Must have understanding of technical and financial aspects of the health insurance industry

Strong personal computer skills, along with the ability to use fraud/abuse data mining tools are required

Must possess excellent communication skills and be detailed oriented

Strong written and oral communication skills

Strong relationship building skills

Client focused with strong business acumen

Self-starter with the ability to work under pressure independently and as part of a team

Ability to think strategically and act proactively to create strong trust and confidence with business units

Strong innovative problem-solving capabilities

Language (Other than English):

None

Travel Requirement:

0% - 25%

Physical, Mental Demands and Working Conditions

Position Type: Office-based

Teaches / trains others regularly Occasionally

Travel regularly from the office to various work sites or from site-to-site Rarely

Works primarily out-of-the office selling products/services (sales employees) Never

Physical work site required Yes

Lifting: up to 10 pounds Constantly

Lifting: 10 to 25 pounds Occasionally

Lifting: 25 to 50 pounds Rarely

Compliance Requirement

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range

Minimum: $62,700.00

Maximum: $97,200.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Diversity and Inclusion

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law. We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.

For accommodation requests, please contact HR Services Online at View email address on click.appcast.io

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