About This Role
Investigating potential fraud, waste, and abuse across various organizational activities is the core of this role. It involves developing and maintaining an anti-fraud program, conducting field investigations, coordinating recovery of misappropriated funds, and preparing cases for legal referral. This position suits an individual who can conduct thorough interviews, perform proactive audits, and potentially testify in court.
Responsibilities
- Perform investigations into potential and existing provider and member fraud, waste, and abuse activities
- Identify 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
- Determine the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctors
- Develop and maintain an annual anti-fraud program, including facilitating fraud training and fraud awareness day, and filing annual fraud plans and reports according to state regulations
- Update annually the changes in insurance laws with regard to lines of business
- Coordinate data extracts by assessing multiple databases both internally and externally
- Take action to prevent further improper payments
- Forward cases to the Credentialing and/or Medical Review Committee, law enforcement, and regulatory agencies
- Complete all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects
- Provide advisory support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee
- Engage in delivery of audit results and overpayment negotiations
- Coordinate recovery/savings of misappropriated funds paid by Highmark and affiliated companies and work with Finance to ensure proper recording in the financial statements
- Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements
- Complete Office of Foreign Asset Control (OFAC) to ensure payments are not issued to unauthorized parties
Requirements
- Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field
Substitutions:
- 6 years of related and progressive experience in lieu of a Bachelor's degree
Preferred:
- Master's Degree in Fraud, Forensics Accounting, Business, or a related field
- 3 years of relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations
