Senior Fraud Analyst
Job ID: J168922
Company: Highmark Inc
Location: Pittsburgh,PA,US
Full/Part Time: Full time
Job Type: Day (United States of America)
AHN Facility:
Posted Date: November 18, 2020
JOB DESCRIPTION
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. 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
- 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
- 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.
- Completes all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.
- Provides support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
- Recover 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
- High School / GED
Substitutions
- None
Preferred
- Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT or closely related field
EXPERIENCE
Required
- 5 years of related work history
Preferred
- 2 years with Financial Analysis in an Acute Care Hospital or Health Insurance setting
- Experience in hospital Patient Financial Services, HIM, Internal Audit, Reimbursement or Contracting departments preferred.
LICENSES or CERTIFICATIONS
Required
- None
Preferred
- Fraud Claims Law Specialist (FCLS)
- Certified Fraud Examiner (CFE)
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.
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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
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
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BENEFITS
Total Rewards Program
In addition to competitive pay rates and flexible career growth, we show our employee appreciation through a comprehensive Total Rewards package, including:
- Medical and prescription drug, dental and vision coverages for your and your eligible dependents
- Health Saving and Flexible Spending Accounts
- Life, AD&D and disability insurance
- Employer-sponsored 401(k) plan
- Paid time off, including paid holidays
- Tuition reimbursement
- Volunteer opportunities
- Voluntary benefits
- Employee discounts
Wellness Resources and Programs
Employees have access to the following wellness programs and resources:
Employees have access to the following wellness programs and resources:
- Work-life resources, such as employee assistance programs and financial counseling services
- 24/7 telephone access to health and wellness coaching to achieve personal goals
- Onsite pharmacy services at major campuses
- Fitness center access for all employees inclusive of showers, lockers, and group exercise classes at major Highmark campuses, Allegheny General Hospital & West Penn Hospital
- Access to chronic condition management programs when enrolled in the employer-sponsored medical plan
- 100% coverage for preventive exams, including flu shots
- Incentive program that rewards employees
- Secure bicycle parking at major campuses
- Healthy food options at onsite cafeterias
- Employee networks to gather in the name of health
- Onsite seated massage and stress management classes including yoga, mindfulness and meditation
LIVING IN PITTSBURGH
Pittsburgh, PA is home to Highmark Health’s corporate headquarters, as well as the headquarters of many of our businesses and a majority of our career opportunities. When you live and work in Pittsburgh, you’ll experience a wide variety of lifestyle advantages. Take a look around and you’ll quickly see why Pittsburgh is one of America’s most liveable, most affordable, safest and happiest cities. Learn more about this exciting and inviting location:
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