Investigator

Job Summary

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. The incumbent 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.

Essential Responsibilities

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities.
• Conducts interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project.
• Develops and maintains annual anti-fraud program which includes facilitating fraud training and fraud awareness day, as well as filing annual fraud plans and reports according to state regulations.
• Coordinates data extracts by assessing multiple databases both internally and externally.
• Completes all necessary field (externally) investigative work for resolution or alleged fraud / waste and abuse cases or special projects.
• Provides advisory support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
• Engages in delivery of audit results and overpayment negotiations.
• Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.

Education

Required : Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field

Substitutions : 6 years of related and progressive experience in lieu of Bachelor's degree

Preferred : Master's Degree in Fraud, Forensics Accounting, Business or related field

Experience

Required : 3 years of relevant, progressive experience in the health insurance industry and / or healthcare fraud investigations

Preferred : 1 year in Financial Analysis in an acute care hospital or health insurance setting

1 year in professional billing, facility Patient Financial Services, HIM, Internal Audit, Professional / Facility Reimbursement or Provider Contracting

Licenses or Certifications

Required : None

Preferred : Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Accredited Healthcare Fraud Investigator (AHFI)

Skills

Must have knowledge of provider facility payment methodology, claims processing systems and coding and billing proficiency

Must have 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 are required

Must possess excellent communication skills and be detailed oriented

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

Physical, Mental Demands and Working Conditions

Position Type : Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products / services (sales employees) Never Physical work site required Yes Lifting : up to 10 pounds Constantly Lifting : 10 to 25 pounds Occasionally Lifting : 25 to 50 pounds Rarely

Disclaimer : The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Pay Range Minimum : $57,700.00 Pay Range Maximum : $107,800.00 Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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