Associate Investigator

Highmark Health•Erie, PA

1d•Onsite

About The Position

The Associate Investigator is responsible for developing and maintaining an anti-fraud program, which includes the development and delivery of training and the filing of Fraud Plans and Reports. This role involves conducting investigations into organizational or functional activities related to alleged fraud, waste, and abuse perpetrated by various entities such as providers, members, facilities, pharmacies, groups, and/or employees of Highmark and its Subsidiaries. The incumbent will conduct interviews, which may be performed both onsite and offsite. Key responsibilities also include field investigative work for special projects or potential fraud, waste, and abuse cases, conducting initial investigations, and coordinating the recovery/savings of funds related to these activities. The Associate Investigator must be prepared to testify in court, prepare cases for referral to federal, state, and local law enforcement entities, and collaborate with these agencies until case closure. Additionally, the role involves conducting audits for proactive and investigative purposes to ensure compliance with internal audit and regulatory requirements.

Requirements

Associate's Degree
3 years of related and progressive experience in lieu of Associate's degree
1 year in Healthcare, Finance, Provider office or related industry
Knowledge of provider facility payment methodology, claims processing systems and coding and billing proficiency
Understanding of technical and financial aspects of the health insurance industry
Strong personal computer skills
Ability to use fraud/abuse data mining tools
Excellent communication skills
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

Nice To Haves

Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or related field
1 year of financial analysis in acute care hospital or health insurance setting
Certified Fraud Examiner (CFE)
Certified Professional Coder (CPC)
Certified Outpatient Coder (COC)
Accredited Healthcare Fraud Investigator (AHFI)

Responsibilities

Conducts investigations of areas or programs as requested both internally and externally using department case protocol.
Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries.
Interviews providers, members or any other individual(s) necessary to complete a case review 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.
Takes action to prevent further improper payments.
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
Completes all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.
Recover 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.
Provides support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
Other duties as assigned or requested.