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 perpetrated by providers, members, facilities, pharmacies, groups, and/or employees of Highmark and its subsidiaries.

The incumbent conducts interviews with providers, members, and other individuals, both onsite and offsite, and performs field investigative work to complete reviews of special projects or potential fraud cases. Responsibilities include coordinating recovery and savings of misappropriated funds, testifying in court, preparing cases for referral to law enforcement, and working with federal, state, and local agencies through case closure. The role also involves conducting audits for proactive and investigative purposes to comply 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 other individuals necessary to complete investigations or special projects.
• 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 insurance laws annually with regard to lines of business.
• Coordinates data extracts by assessing multiple internal and external databases to prevent improper payments.
• Forwards cases to Credentialing and/or Medical Review Committees, 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.
• Responsible for recovery and savings of misappropriated funds and works with Finance to ensure proper recording in financial statements.
• Conducts audits for proactive and investigative purposes, including contract, 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 or 6 years of related and progressive experience in lieu of a degree.
• 3 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 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 trust and confidence with business units.
• Strong innovative problem-solving capabilities.

Preferred Qualifications

• Master's Degree in Fraud, Forensic Accounting, Business, or a related field.
• 1 year of experience in financial analysis in an acute care hospital or health insurance setting.
• 1 year of experience in professional billing, facility Patient Financial Services, Health Information Management (HIM), Internal Audit, Professional/Facility Reimbursement, or Provider Contracting.
• Certifications such as Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), or Accredited Healthcare Fraud Investigator (AHFI).

Skills

• Strong communication and interpersonal skills.
• Client-focused with a proactive approach.
• Ability to work in a team or independently under pressure.
• Strategic thinking and problem-solving capabilities.

Working Conditions

• Office-based position with occasional travel (0% - 25%) to various work sites.
• Occasionally teaches or trains others.
• Physical work site required.
• Constantly lifts up to 10 pounds; occasionally lifts 10 to 25 pounds; rarely lifts 25 to 50 pounds.

Pay

Base pay range: $62,700.00 - $97,200.00. Base pay is determined by a variety of factors including qualifications, experience, expected contributions, internal peer equity, market, and business considerations. Geographic differentials may apply for certain locations based on comparative markets.