Job Description

Anti-Fraud Program Manager

Company: Highmark Inc.

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.
• Conducts interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project.
• Develops and maintains 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.
• Coordinates data extracts by assessing multiple databases both internally and externally. Takes action to prevent further improper payments.
• Completes all necessary field 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 agencies, Credentialing or Medical Review Committee.
• Engages in delivery of audit results and overpayment negotiations. Responsible for recovery/savings of 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.

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: 3 years of relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations
• Preferred: 1 year in Financial Analysis in an acute care hospital or health insurance setting
• 1 year 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 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
• 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
• 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. 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. 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.

Pay Range Minimum: $57,700.00

Pay Range Maximum: $107,800.00

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.

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