Lead Investigator

Highmark Health•Pittsburgh, PA

1d•Onsite

About The Position

This 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 job 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

Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field OR 6 years of related and progressive experience in lieu of Bachelor's degree
7 years in the Health Insurance industry and/or Healthcare Fraud investigations
3 years of experience 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
Excellent communication skills and attention to detail
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
Compliance with ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Compliance with HIPAA and data security guidelines.

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 Outpatient Coder (COC)
Accredited Healthcare Fraud Investigator (AHFI)
CPMA, CCA, or CCS

Responsibilities

Monitoring and coordinating investigative activities for the team.
Serving as team lead and subject matter expert for Investigators, providing guidance and training/mentoring to other team members.
Performing investigations into potential and existing provider and member fraud, waste and abuse activities.
Identifying parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries.
Conducting interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project.
Determining the scope of the allegation or special project by assembling necessary information, statistics, policies and procedures, licensure information, doctors’ agreements, contracts, etc.
Developing and maintaining an annual anti-fraud program, including facilitating fraud training and fraud awareness day, and filing annual fraud plans and reports according to state regulations.
Updating annually on changes in insurance laws with regard to lines of business.
Completing all necessary field (externally) investigative work for resolution of alleged fraud/waste and abuse cases or special projects.
Providing advisory support to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
Engaging in delivery of audit results and overpayment negotiations.
Conducting audits for proactive and investigative purposes to comply with internal audit and regulatory requirements, including contract, commissions, surveillance, workers’ compensation, IME, and Office of Foreign Asset Control (OFAC) audits.
Coordinating data extracts by assessing multiple databases both internally and externally.
Taking action to prevent further improper payments.
Forwarding cases to the Credentialing and/or Medical Review Committee, law enforcement and regulatory agencies.
Testifying in a court of law.
Preparing cases for referral to various federal, state and local law enforcement entities and working with those agencies through closure of the case.