Investigator

Highmark Health•Pittsburgh, PA

26d•Onsite

About The Position

This job is responsible for developing and maintaining an anti-fraud program, including delivering training and filing fraud plans and reports. The Investigator examines alleged fraud, waste, and abuse involving providers, members, facilities, pharmacies, groups, and employees of Highmark and its subsidiaries. Work includes interviewing relevant parties, conducting onsite or offsite and other field investigations, determining the scope of allegations or special projects, and coordinating the recovery or savings of funds related to improper payments. The role may require testifying in court, preparing cases for referral to federal, state, and local law enforcement, and working with those agencies through case closure. The Investigator also conducts proactive and investigative audits to meet internal audit and regulatory requirements. The position is office-based and may involve occasional training and rare travel between work sites. Travel requirement is 0%–25%. Physical demands include lifting up to 10 pounds constantly, 10–25 pounds occasionally, and 25–50 pounds rarely. The role must comply with applicable ethical, legal, privacy, and information-security requirements, including HIPAA and company policies.

Requirements

Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field; alternatively, six years of related and progressive experience may substitute for the degree.
Three years of relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations.
Knowledge of provider facility payment methodology, claims processing systems, and coding and billing.
Understanding of the technical and financial aspects of the health insurance industry.
Strong personal computer skills and ability to use fraud/abuse data-mining tools.
Excellent, detailed-oriented communication skills, including strong written and oral communication.
Strong relationship-building skills and a client-focused approach with business acumen.
Ability to work independently and as part of a team under pressure.
Ability to think strategically and act proactively to build trust and confidence with business units.
Strong innovative problem-solving capabilities.

Nice To Haves

Master’s degree in Fraud, Forensics Accounting, Business, or a related field.
One year of experience in financial analysis in an acute care hospital or health insurance setting.
One year of experience 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 Outpatient Coder (COC), or Accredited Healthcare Fraud Investigator (AHFI).

Responsibilities

Investigate potential and existing provider and member fraud, waste, and abuse; review inquiries and complaints and identify parties involved.
Interview providers, members, and other individuals as needed to complete investigations or special projects.
Determine the scope of allegations or projects by gathering relevant information, statistics, policies and procedures, licensure information, agreements, and contracts.
Develop and maintain the annual anti-fraud program, facilitate fraud training and fraud awareness activities, and file annual fraud plans and reports in accordance with state regulations.
Update information annually regarding changes in insurance laws for relevant lines of business.
Coordinate data extracts by assessing internal and external databases, take action to prevent further improper payments, and refer cases to Credentialing and/or Medical Review Committees, law enforcement, or regulatory agencies.
Complete external field investigative work needed to resolve alleged fraud, waste, and abuse cases or special projects.
Provide advisory support to internal and external law enforcement and regulatory agencies, Credentialing, and Medical Review Committees.
Deliver audit results and negotiate overpayments; coordinate recovery or savings of misappropriated funds and work with Finance to ensure proper recording in financial statements.
Conduct proactive and investigative audits to meet internal audit and regulatory requirements, including contract, commissions, surveillance, workers’ compensation, IME, and Office of Foreign Asset Control (OFAC) audits.
Prepare cases for referral to law enforcement, work with agencies through case closure, and testify in court when required.
Perform other duties as assigned or requested.