Investigations Consultant

Highmark; Pittsburgh (Allegheny County); On-site; USD 80,000 - 100,000; Full time

Job summary

Highmark is seeking an experienced auditor responsible for developing and implementing strategic auditing plans in Pittsburgh. This role requires collaboration with teams to identify overbilling and implement recovery strategies, along with thorough investigations in compliance with regulations.

Qualified candidates will have a Bachelor's degree and extensive experience in the health insurance industry, especially in fraud investigations. The position is office-based and offers opportunities for mentorship and project leadership.

Qualifications

• 7+ years in health insurance industry and/or healthcare fraud investigations.
• 3+ years leading projects of varying size and complexity.
• Knowledge of claims processing systems.

Responsibilities

• Analyze claim processes to identify risk areas.
• Collaborate to identify overbilling and audit approaches.
• Perform claims system extracts and report trends.

Skills

Knowledge of provider facility payment methodology

Strong communication skills

Technical and financial understanding of health insurance

Proficiency in coding and billing

Data-mining tools usage

Education

Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field

Master’s degree in Fraud, Forensics Accounting or related field (preferred)

Job description

Company: Highmark Inc.

Job Summary

This position is responsible for development and implementation of strategic audit plans utilizing numerous inputs including contracts, industry trends and revenue maximization schemes. The incumbent will work with audit team members and external vendors to develop specific auditing techniques to identify overbilling and potential recoveries/savings. As a subject‑matter expert for investigations the role provides guidance and mentoring to the investigative team, must be able to testify in a court of law, prepare cases for referral to federal, state and local law enforcement, 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 for professional, hospital, ambulatory surgical center, home health and durable medical equipment to identify key risk areas and develop mitigation and recovery plans.
• Collaborate with audit teams and external vendors to identify overbilling, determine data‑analysis routines and audit approaches.
• Work with operational areas to recover identified overpayments, performing follow‑up reviews to ensure correct claim adjustments and expected recoveries/savings.
• Perform claims system extracts and create reports, graphs, and charts to identify trends and patterns of potential healthcare fraud, waste, and abuse; communicate findings to management and various stakeholders.
• Calculate overpayments in established fraud, waste or abuse cases, identify all fraudulent activity, determine involved lines of business, and measure overpayment by 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.
• Act as a project lead for special investigation projects of varying complexity.
• Perform 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 a 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 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

• Knowledge of provider facility payment methodology, claims processing systems, and coding and billing proficiency.
• Understanding of technical and financial aspects of the health insurance industry.
• Strong personal computer skills and ability to use fraud/abuse data‑mining tools.
• Excellent communication skills, detail oriented, and strong written and oral abilities.
• Strong relationship‑building skills and client‑focused business acumen.
• Self‑starter capable of working under pressure independently and as part of a team.
• Strategic thinker who acts proactively to build trust and confidence with business units.
• Innovative problem‑solving capabilities.

Other Requirements

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.
• Never: Works primarily out‑of‑the office selling products/services (sales employees).
• Yes: Lifting up to 10 pounds.
• Constantly: Lifting 10 to 25 pounds.
• Occasionally: Lifting 25 to 50 pounds.
• Rarely: [No additional physical demands specified.]

EEO Statement

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. For accommodation requests, please contact HR Services Online at [e-mail]. California Consumer Privacy Act Employees, Contractors, and Applicants Notice.