Investigator

Highmark Health / AHN; New York (NY); On-site; USD 90,000 - 140,000; Full time

Job summary

Highmark Inc. is seeking an anti-fraud investigator responsible for developing and maintaining an anti-fraud program and conducting investigations of fraud, waste and abuse across providers, members, facilities, pharmacies, groups and employees.

Interviews may be conducted on-site or off-site, with field work required for special projects. The incumbent will prepare cases for referral to law enforcement and regulatory agencies, testify in court when needed, and ensure compliance with internal

Qualifications

• Investigations into potential and existing provider and member fraud, waste and abuse activities.
• Ability to interview providers, members and other individuals to complete investigations.
• Knowledge of fraud, waste and abuse reporting and regulatory considerations.

Responsibilities

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities. Identifies involved parties by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and employees.
• Develop and maintain annual anti-fraud program including fraud training and awareness, and filing annual fraud plans and reports according to state regulations.
• Coordinates data extracts by assessing multiple databases and takes action to prevent improper payments; forwards cases to relevant committees and law enforcement.
• Conducts field investigative work for resolution of fraud/waste and abuse cases or special projects; may testify in court and coordinate with agencies.
• Provides advisory support to internal and external law enforcement and regulatory bodies.

Job description

## Company :

Highmark Inc.

## Job Description :

JOB SUMMARY

This job is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. The incumbent is responsible for conducting investigations 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. The incumbent 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 investigations and coordinating the recovery/savings 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

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities. Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries. Conduct Interviews with providers, members or any other individual(s) necessary to complete an assigned investigation 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.
• 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
• 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.
• Responsible for completing all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.
• Provides advisory support as needed to internal and external law enforcement and regulatory