Overview

GENERAL OVERVIEW:

The incumbent is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. This position is responsible for conducting reviews 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. This position 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 reviews and coordinating the recovery 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:

1. 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

2. Conducts reviews of areas or programs as requested both internally and externally using department case protocol.

  • Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries.
  • Interviews providers, members or any other individual(s) necessary to complete a case review 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.
  • 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.

3. Completes all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.

4. Provides support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.

5. Recover misappropriated funds paid by Highmark and affiliated companies and work with Finance to ensure proper recording the financial statements.

6. 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.

7. Other duties as assigned or requested.

QUALIFICATIONS:

Education, Licenses/Certifications, and Experience

Minimum

  • A High School Diploma/GED
  • 0-1 years of relevant subject matter experience in the area of specialization

Preferred

  • Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT or closely related field.
  • two (2) years financial analysis experience in acute care hospital or health insurance setting.
  • Experience in hospital Patient Financial Services, HIM, Internal Audit, Reimbursement or Contracting departments preferred.
  • FCLS fraud claims law specialist
  • Certified Fraud Examiner (CFE)


Knowledge, Skills and Abilities

  • 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.


SCOPE OF RESPONSIBILITY

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is Travel Required?

Yes

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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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

EEO is The Law

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