Company :
Highmark Inc.Job Description :
JOB SUMMARY
This job is responsible for development and implementation of strategic audit plans utilizing numerous inputs including contracts, industry trends and revenue maximization schemes. The incumbent will also work with other audit team members and external vendors to develop specific auditing techniques to identify overbilling and potential recoveries/ savings. Incumbent is responsible for coordinating and overseeing all aspects of cases that are referred to law enforcement agencies. This oversight includes maintaining and developing a relationship with the law enforcement and reviewing case referral communications to the agencies.
ESSENTIAL RESPONSIBILITIES
- Serve as the single point of contact for law enforcement. Work with the various agencies on strategies for completing fraud investigations that maximize the likelihood of prosecution.
- Coordination and oversight of all aspects of cases that are referred to law enforcement agencies.
- Developing and maintaining a relationship with local, state and federal law enforcement agencies.
- Analyze and evaluate claim processes specific to professional, hospital, ambulatory surgical center, home health and durable medical equipment to identify key areas of risk exposure and develop plans to mitigate risks and maximize financial recoveries/ savings.
- Work with audit teams and external audit vendors to identify overbilling, determine data analysis routines and audit approaches.
- Work with operational areas to recover identified overpayments, performing a follow-up review to ensure that the claims were adjusted correctly, resulting in expected recovery/ saving.
- Perform claims system extracts and create reports, graphs, and charts to timely identify trends and patterns of potential healthcare fraud, waste and abuse. Communicate findings to company management of various areas including provider relations, reimbursement etc.
- Calculate overpayments in established fraud, waste or abuse cases. Identify all fraudulent activity included in the case, determine what lines of business were involved in the fraudulent activity, and measure overpayment by means of sampling or complete review. Negotiate settlements with providers.
- Maintain current case related information on all applicable case management tracking systems.
- Provide investigative support and mentoring to investigative team members. Function as a project lead for special investigation projects of varying complexity.
- 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 in Fraud, Forensics Accounting, Business or related field
EXPERIENCE
Required
- 10 years in the Health Insurance industry and/or Healthcare Fraud investigations
- 3 years working with law enforcement on fraud cases through civil or criminal prosecutions
- 3 years of leading projects of varying size and complexity
Preferred
- 5 years of 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
- Institutional Pricing Knowledge and experience
LICENSES or CERTIFICATIONS
Required
- None
Preferred
- Certified Fraud Examiner (CFE)
- Certified Professional Coder (CPC)
- Certified Professional Coder- Hospital(CPC-H)
- Certified Outpatient Coder (COC)
- Accredited Healthcare Fraud Investigator (AHFI)
SKILLS
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.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
California Consumer Privacy Act Employees, Contractors, and Applicants Notice