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. This job 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

• Responsible for monitoring and coordinating investigative activities for the team. Initial point of contact for internal and external team members and will assist in problem solving and decision making throughout the investigation process.
• Serves as team lead and 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.
• 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.
• 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.
• 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.
• Other duties as assigned or requested.

Full-time responsibilities for WV Medicaid including the following:

• Initiate investigations and develop FWA cases for future action.
• Follow up appropriately on program integrity leads from BMS.
• Execute and respond to requests for information (RFIs) from the MFCU, including MFCU data requests.
• Execute and respond to RFIs from BMS, or other State actors.
• Act as the point of contact for program integrity deconfliction.
• Participate in West Virginia-based training, task forces, and other relevant meetings.

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

• 7 years in the Health Insurance industry and/or Healthcare Fraud investigations
• 3 years of in leading projects of varying size and complexity

Preferred

• 5 years in Financial Analysis in an acute care hospital or health insurance setting
• 5 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)
• CPMA, CCA, or CCS

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

Constantly

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.