Lead Investigator

Company :

Highmark Inc.

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.

This job 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.

• Responsible for monitoring and coordinating investigative activities for the team. Initial point of contact for internal and external team members and will assist in problem solving and decision making throughout the investigation process.

• Serves as team lead and subject matter expert for Investigators. Will provide guidance and help train/mentor other team members. Could serve as a project lead for special projects within the department.

• 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.

• 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 agencies, Credentialing or Medical Review Committee.

• Engages in delivery of audit results and over payment 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.

• 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.

• Other duties as assigned or requested.

• Initiate investigations and develop FWA cases for future action.

• Follow up appropriately on program integrity leads from BMS.

• Execute and respond to requests for information (RFIs) from the MFCU, including MFCU data requests.

• Execute and respond to RFIs from BMS, or other State actors.

• Act as the point of contact for program integrity deconfliction.

• Participate…