Investigation Associate

Company:

Highmark Inc.

Job Description:

JOB SUMMARY

Join Highmark Inc. as an Investigation Associate, where you will play a critical role in our anti-fraud program. This position involves creating and delivering training, filing Fraud Plans and Reports, and conducting investigations into possible fraud, waste, and abuse by providers, members, facilities, pharmacies, and employees. You will be responsible for interviews and field investigations to ensure thorough reviews of special projects and potential fraud cases. You may also prepare cases for law enforcement referral and work alongside various agencies until closure of investigations.

ESSENTIAL RESPONSIBILITIES

Conduct thorough investigations as requested both internally and externally, adhering to departmental protocols. Review complaints and inquiries against providers, members, and other stakeholders, interviewing necessary parties to finalize case reviews and special projects.

Recover funds misappropriated from Highmark and associate companies, collaborating with Finance for accurate financial statements.

Perform audits for both proactive and investigative purposes, ensuring compliance with internal and regulatory requirements.

Provide support to law enforcement and regulatory agencies as needed, as well as internal committees.

Handle additional duties as assigned or requested.

EDUCATION

Required

Associate's Degree

Substitutions

3 years of related experience may substitute for an Associate's degree.

Preferred

Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field.

EXPERIENCE

Required

1 year in Healthcare, Finance, or a related industry.

Preferred

Experience in financial analysis within a health insurance setting or health provider billing office.

LICENSES or CERTIFICATIONS

Required

None

Preferred (any of the following)

Certified Fraud Examiner (CFE)

Certified Professional Coder (CPC)

Certified Outpatient Coder (COC)

Accredited Healthcare Fraud Investigator (AHFI)

SKILLS

Strong knowledge of provider payment methodologies and claims processing.

Comprehensive understanding of the financial aspects of the health insurance industry.

Proficient in utilizing fraud detection and data mining tools.

Excellent communication skills with a meticulous attention to detail.

Ability to build strong relationships, demonstrating client focus and business insight.

Self-motivated individual, capable of independent work and thriving under pressure.

Strategic thinker with a proactive approach to problem-solving.

Language (Other than English):

None

Travel Requirement:

0% - 25%

WORKING CONDITIONS

Office-based position with rare travel to various sites required. The role involves physical activities including lifting up to 25 pounds occasionally.

Disclaimer: This job description outlines the general nature and essential duties of this role, but may not encompass all responsibilities.

Pay Range Minimum: $24.53

Pay Range Maximum: $38.76

Base pay is influenced by factors such as qualifications, experience, and market conditions.

Highmark Health promotes equality and prohibits discrimination. For assistance during the application process, please contact HR Services.

Req ID: J277916