Senior Investigator

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

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. 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. 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.

• 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.

• 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.

• Will be called upon as a subject matter expert for Investigators. Will provide guidance and help train/mentor other team members. Could serve as a project lead for special projects within the department.

• 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

• 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 Fraud, Forensics Accounting, Business or related field

EXPERIENCE

Required

• 5 years in the Health insurance industry and/or Healthcare fraud investigations

• 1 year of leading projects of varying size and complexity

Preferred

• 3 years of financial analysis in an acute care hospital or health insurance setting

• 3 years 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

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

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.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

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.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice (https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib\_458575\_QLVK9\_1769448333304228022\_1769448333396/1769448333396.pdf)

Req ID: J289839