Associate Investigator

Highmark Health•Pittsburgh, PA

12d•Onsite

About The Position

JOB SUMMARY The 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. This 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.

Requirements

Associate's Degree or 3 years of related and progressive experience in lieu of Associate's degree
1 year in Healthcare, Finance, Provider office or related industry
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

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.