Senior Compliance Investigator

Job Description : JOB SUMMARY The incumbent 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 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. 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.Conduct 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.
Coordinates data extracts by assessing multiple databases both internally and externally.Forwards case to the Credentialing and/or Medical Review Committee, law enforcement and regulatory agencies.
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.
Will provide guidance and help train/mentor other team members. Could serve as a project lead for special projects within the department.
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.
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 Fraud, Forensics Accounting, Business or related field
EXPERIENCE Required 5 years in the Health insurance industry and/or Healthcare fraud investigations
1 year of leading projects of varying size and complexity
Preferred 3 years of financial analysis in an acute care hospital or health insurance setting
3 years in professional billing, facility Patient Financial Services, HIM, Internal Audit, Professional/Facility Reimbursement or Provider Contracting
Preferred Certified Fraud Examiner (CFE)
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
Strong relationship building skills
Ability to think strategically and act proactively to create strong trust and confidence with business units
Language (Other than English): None
Travel Requirement: 0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS Position Type Office-based
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
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.
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.
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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. 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.

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