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Manager Provider Audit

Highmark Wholecare

  • Company April 2022 Ed (1)
  • Pittsburgh, PA
  • Audit & Compliance
  • Full time
  • Day (United States of America)

Company :

Highmark Wholecare

Job Description : 


This job is responsible for the daily activities of the provider integrity department, detection and investigation of fraud, waste and abuse (FWA) and the recoupment of related over payments related to the company’s provider spending. The incumbent will function as a key leader guiding all of the daily activities for one or more strategic units within the department: investigative unit, vendor audit teams, technology and management reporting, FWA and financial recovery identification team, and regulatory compliance team.


  • Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
  • Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
  • Deliver daily guidance to team leads and staff regarding case investigation activities including the development of detailed strategies for each case. Educate staff and management on regulatory and customer requirements regarding scope of activities and ensure adherence to these requirements. Serve as subject matter expert for staff on the fraud investigation, facility and vendor audit and opportunity teams.
  • Provide daily guidance to staff regarding investigations of various doctors, hospitals and other providers.
  • Develop action plans and priorities for various recovery opportunities with a focus on the continual increase in financial impact generated by investigation and analysis activities.
  • Actively communicate and collaborate with management from various departments regarding impact on provider relations and reimbursement.
  • Provide suggestions on and/or participate in department projects, process improvements, efficiency initiatives, system enhancements and policy and procedures to improve workflows.
  • Serve in a variety of capacities in representing the department, including but not limited to such activities as:
  • • Work with audit vendors to refine their approaches and generate consistent increase in their recoveries.
  • • Testify when required in legal proceedings.
  • • Serve as liaison for the company’s customers as it relates to fraud, waste and abuse (FWA) program and fraud awareness trainings.
  • • Collaborate with law enforcement in the pursuit of cases referred for prosecution
  • • Interacte with external legal counsel regarding case inquiries
  • • Collaborate with other business units to ensure that appropriate policy and/or system changes occur to minimize fraud, waste and abuse (FWA) perpetrated against the company.
  • Assist in the communication of audit strategies throughout the company. Manage staff to ensure a culture of continuous improvement by all employees.
  • Implement processes to utilize data generated by technology tools to enhance investigations and vendor audits. Participate in external meetings/discussions to stay informed regarding current fraud, waste and abuse (FWA) schemes and potential investigation approaches to combat schemes. Work with management to develop quarterly opportunity assessments used to direct the development of data analytics, and focus the use of resources.
  • Other duties as assigned or requested.


Bachelor's Degree - Business, Finance, Accounting, Healthcare Administration


6 years' minimum experience in auditing, consulting and/or fraud, waste and abuse (FWA)


Master’s Degree - Business Administration



  • 5 years' combined experience auditing, leading provider/facility audits and/or provider reimbursements, working with law enforcement, claims billing, coding, benefits, enrollment or external relationship management (vendors, regulatory agencies or healthcare industry groups).
  • 3 years' combined experience of (1) overpayment identification resulting from claims billing including completion of inquiries on claim charges from providers or customers and/or from the claim processing operations (2) fraud, waste and abuse (FWA) investigations  (3) audit consulting experience in the healthcare or Finance related fields with strong relationship and project management skills
  • 3 years' combination of managerial/supervisory experience or leadership experience
  • 3 years' related experience in claims analysis and/or investigations activities (for Operations area).


  • 3 years' experience in provider claim review and recoveries
  • 3 years' experience in fraud, waste & abuse (FWA) related investigations, utilization review payment or hospital reimbursement
  • Significant experience in monitoring and measurement of financial impact of activities


  • Strong and effective verbal and written communication skills; Effectively presents complex topics in a concise manner to audiences at various levels and various sizes; Demonstrates the ability to effectively persuade others to listen, commit, and act on a new approach
  • Knowledge of hospital reimbursement strategies; medical technologies, hospital and provider office protocols, documentation requirements, State and Federal criminal and civil law related to insurance fraud and advances in the post-payment utilization review process
  • Proven leadership skills - ability to motivate others to quickly achieve results in a matrixed environment; Successful experience in achieving results through people in a complex environment
  • Working knowledge of the various claims processing systems for professional and/or facility claims
  • Self-confident with an ability to accept and respond to challenges in a positive manner




Accredited Health Care Fraud Investigator (AHFI), Certified Fraud Examiner (CFE) or Certified Public Accountant


0%  - 25%

LANGUAGE REQUIREMENT ( other than English )?   


( The physical, mental demands and working conditions described here are representative of those that must be met by an employee to successfully perform the essential function of their job. Reasonable accommodations will be made when necessary to enable individuals with disabilities to perform the essential duties of the position, to the extent that they do not cause undue hardship.

Position Type:


Office-Based Positions

An employee in this position works in an office environment.  The position frequently requires the employee to communicate effectively with others both inside and outside the workplace (e.g., in person, via telephone, via email).  The employee must be able to understand, interpret and analyze data, solve problems, concentrate, and research, use available technological resources and systems (e.g., computers and computer programs), multi-task, prioritize, and meet multiple deadlines to complete essential tasks.  The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis as well as adhere to all workplace policies, and may be called upon to work outside regular business hours.

Teaches/Trains others regularly  


Travels regularly from the office to various work sites or from site-to-site Occasionally

Works primarily out-of-the office selling products/services (Sales employees)

Does Not Apply

Physical Work Site Required  


Lifting: up to 10 pounds


Lifting: 10 to 25 pounds  


Lifting: 25 to 50 pounds  



Changes Approved By:

Melanie Lysne

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 position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

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, age, 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, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( )

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