Investigations Consultant

Highmark Health•Pittsburgh, PA

2d•Onsite

About The Position

This job is responsible for development and implementation of strategic audit plans utilizing numerous inputs including contracts, industry trends and revenue maximization schemes. The incumbent will also work with other audit team members and external vendors to develop specific auditing techniques to identify overbilling and potential recoveries/ savings. Will be called upon as a subject matter expert for investigations providing guidance and mentoring to investigative team. 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

Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field
6 years of related and progressive experience in lieu of Bachelor's degree
7 years of in the Health Insurance industry and/or Healthcare Fraud investigations
3 years in leading projects of varying size and complexity
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, along with the ability to use fraud/abuse data mining tools are required
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

Master's degree in Fraud, Forensics Accounting, Business or related field
5 years in Financial Analysis in an acute care hospital or health insurance setting
5 years in professional billing, facility Patient Financial Services, HIM, Internal Audit, Professional/Facility Reimbursement or Provider Contracting
Certified Fraud Examiner (CFE)
Certified Professional Coder (CPC)
Certified Professional Coder- Hospital(CPC-H)
Certified Outpatient Coder (COC)
Accredited Healthcare Fraud Investigator (AHFI)

Responsibilities

Analyze and evaluate claim processes specific to professional, hospital, ambulatory surgical center, home health and durable medical equipment to identify key areas of risk exposure and develop plans to mitigate risks and maximize financial recoveries/savings.
Work with audit teams and external audit vendors to identify overbilling, determine data analysis routines and audit approaches.
Work with operational areas to recover identified overpayments, performing a follow-up review to ensure that the claims were adjusted correctly, resulting in expected recovery/savings.
Perform claims system extracts and create reports, graphs, and charts to timely identify trends and patterns of potential healthcare fraud, waste and abuse.
Communicate findings to company management of various areas including provider relations, reimbursement etc.
Calculate overpayments in established fraud, waste or abuse cases.
Identify all fraudulent activity included in the case, determine what lines of business were involved in the fraudulent activity, and measure overpayment by means of sampling or complete review.
Negotiate settlements with providers.
Maintain current case related information on all applicable case management tracking systems.
Provide investigative support and mentoring to investigative team members.
Function as a project lead for special investigation projects of varying complexity.
Other duties as assigned or requested.

Benefits

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.
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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Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network.
Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services.
Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.