Senior Investigator

Highmark Health•Pittsburgh, PA

1d•Onsite

About The Position

The Senior Investigator develops and maintains an anti-fraud program, including delivering fraud training and filing required fraud plans and reports. The role investigates alleged fraud, waste, and abuse involving providers, members, facilities, pharmacies, groups, and employees of Highmark and its subsidiaries. Investigations may include onsite or offsite interviews, field work, audits, data analysis, payment prevention, and coordination of recoveries or savings. The incumbent prepares cases for referral to law enforcement and regulatory agencies, may testify in court, and works with relevant agencies through case closure. The position also supports internal audit and regulatory compliance through proactive and investigative audits. The role serves as a subject matter expert for investigators, provides guidance and mentoring, and may lead departmental special projects. It also supports internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committees, and coordinates with Finance to ensure recovered funds are properly recorded. The position is office-based, with a stated travel requirement of 0%–25%.

Requirements

Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field, or six years of related and progressive experience in lieu of a bachelor’s degree.
Five years of experience in the health insurance industry and/or healthcare fraud investigations.
One year of experience leading projects of varying size and complexity.
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 and abuse data-mining tools.
Excellent attention to detail and 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, Forensic Accounting, Business, or a related field.
Three years of financial analysis experience in an acute care hospital or health insurance setting.
Three years of experience in professional billing, facility Patient Financial Services, Health Information Management (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).

Responsibilities

Investigate potential and existing provider and member fraud, waste, and abuse, including identifying involved parties and reviewing inquiries and complaints.
Interview providers, members, and other individuals as needed for investigations or special projects.
Determine the scope of allegations or projects by gathering relevant information, statistics, policies, procedures, licensure information, agreements, and contracts.
Coordinate data extracts and assess multiple internal and external databases.
Take action to prevent further improper payments and refer cases to Credentialing or Medical Review Committees, law enforcement, and regulatory agencies.
Develop and maintain the annual anti-fraud program, facilitate fraud training and fraud awareness day, and file annual fraud plans and reports in accordance with state regulations.
Update information annually on changes in insurance laws affecting lines of business.
Serve as a subject matter expert, provide guidance, and train or mentor other team members; potentially lead departmental special projects.
Complete field investigative work required to resolve alleged fraud, waste, and abuse cases or special projects.
Provide advisory support to law enforcement and regulatory agencies, Credentialing, and Medical Review Committees.
Deliver audit results, negotiate overpayments, and coordinate recovery or savings of misappropriated funds with Finance for appropriate financial recording.
Conduct proactive and investigative audits involving contracts, commissions, surveillance, workers’ compensation, and independent medical examinations (IME).
Complete Office of Foreign Asset Control (OFAC) reviews to ensure payments are not issued to unauthorized parties.
Perform other duties as assigned or requested.