Investigator

Description

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.Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and / or employees of Highmark and Subsidiaries.Conduct Interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project.Determines the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctors’ agreements, contract, etc.
• Develop and maintain 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. Responsible for updating annually the changes in insurance laws with regard to lines of business
• Coordinates data extracts by assessing multiple databases both internally and externally.Takes action to prevent further improper payments.Forwards case to the Credentialing and / or Medical Review Committee, law enforcement and regulatory agencies.
• Responsible for completing 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.Responsible for recovery / savings of misappropriated funds paid by Highmark and affiliated companies and work with Finance to ensure proper recording the financial statements.
• Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements. Audits consist of contract, commissions, surveillance, workers’ compensation and IME. In addition, this position will complete Office of Foreign Asset Control (OFAC) to ensure payments are not issued to unauthorized parties.
• Other duties as assigned or requested.

EDUCATION

Required

Substitutions

Preferred

EXPERIENCE

Required

Preferred

LICENSES or CERTIFICATIONS

Required

Preferred (any of the following)

SKILLS

Language (Other than English) :

None

Travel Requirement : 0% - 25%

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

Pay Range Minimum : $57,700.00

Pay Range Maximum : $107,800.00

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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