Investigations Consultant

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. Will be called upon as a subject matter expert for investigations providing guidance and mentoring to investigative team. 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

• 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/savings.
• 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

• 7 years of in the Health Insurance industry and/or Healthcare Fraud investigations 
• 3 years 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 Professional Coder- Hospital(CPC-H)
• Certified Outpatient Coder (COC)
• Accredited Healthcare Fraud Investigator (AHFI)

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

Frequently

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.

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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