Investigator

About the Role

This position is responsible for developing and maintaining an anti-fraud program, including the development and delivery of training, filing of Fraud Plans and Reports, and conducting investigations into alleged fraud, waste, and abuse. The role involves interviewing providers, members, and other individuals, as well as coordinating recovery and savings related to fraudulent activities. The incumbent must prepare cases for referral to law enforcement, testify in court, and ensure compliance with internal audit and regulatory requirements.

Responsibilities

• Performs investigations into potential and existing provider and member fraud, waste, and abuse activities.
• Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries.
• Conducts interviews with providers, members, or any other individuals necessary to complete an assigned investigation or special project.
• Determines the scope of allegations or special projects by assembling necessary information, statistics, policies, procedures, licensure details, doctors’ agreements, and contracts.
• Develops and maintains an annual anti-fraud program, including facilitating fraud training, fraud awareness initiatives, and filing annual fraud plans and reports according to state regulations.
• Updates changes in insurance laws related to lines of business.
• Coordinates data extracts by assessing multiple databases both internally and externally and takes action to prevent further improper payments.
• Forwards cases to the Credentialing and/or Medical Review Committee, law enforcement, and regulatory agencies.
• Completes all necessary field investigative work for resolution of alleged fraud, waste, and abuse cases or special projects.
• Provides advisory support to internal and external law enforcement, regulatory agencies, Credentialing, or Medical Review Committees.
• Engages in delivery of audit results and overpayment negotiations, ensuring recovery and savings of misappropriated funds.
• Works with Finance to ensure proper recording of financial recoveries in financial statements.
• Conducts audits for proactive and investigative purposes, including contract audits, commissions, surveillance, workers’ compensation, and Independent Medical Examinations (IME).
• Completes Office of Foreign Asset Control (OFAC) checks to ensure payments are not issued to unauthorized parties.
• Performs other duties as assigned or requested.

Requirements

• Bachelor’s Degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field. 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 proficiency.
• 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 communication skills, both written and oral, with strong attention to detail.
• Strong relationship-building skills and client-focused 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 build trust and confidence with business units.
• Strong innovative problem-solving capabilities.

Qualifications

Preferred Education: Master’s Degree in Fraud, Forensic Accounting, Business, or a related field.

Preferred Experience:

• One year in financial analysis in an acute care hospital or health insurance setting.
• One year in professional billing, facility Patient Financial Services, Health Information Management (HIM), Internal Audit, Professional/Facility Reimbursement, or Provider Contracting.

Preferred Certifications (any of the following):

• Certified Fraud Examiner (CFE)
• Certified Professional Coder (CPC)
• Certified Outpatient Coder (COC)
• Accredited Healthcare Fraud Investigator (AHFI)
• CPMA, CCA, or CCS

Schedule

• Position Type: Office-based
• Travel Requirement: 0% - 25%
• Physical work site required: Yes
• Teaches/trains others: Occasionally
• Travel between office and work sites: Regularly
• Works primarily out-of-office (e.g., sales): Never

Physical and Mental Demands

• Lifting up to 10 pounds: Constantly
• Lifting 10 to 25 pounds: Occasionally
• Lifting 25 to 50 pounds: Rarely