Fraud Consultant

Job ID: J126533
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at:

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Description

I.    GENERAL OVERVIEW:  
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 also work with other audit team members and external vendors to develop specific auditing techniques to identify overbilling and potential recoveries.  Incumbent will coordinate and oversee all aspects of vendor audit activities with minimal guidance by management.  Vendor oversight to include reviewing vendor communications to facilities and identification and resolution of all discrepancies identified by vendors. 

In the senior consultant job, responsible for coordinating and overseeing all aspects of cases that are referred to law enforcement agencies.  This oversight includes maintaining and developing a relationship with the law enforcement and reviewing case referral communications to the agencies.

II.    ESSENTIAL RESPONSIBILITIES:  
1.    Analyze and evaluate claim processes specific to hospital, ambulatory surgical center, home health and durable medical equipment vendors to identify key areas of risk exposure and develop plans to mitigate risks and maximize financial recoveries.  

2.    Work with audit team and external audit vendors to identify overbilling, determine data analysis routines and audit approaches.  
3.    Work with operational areas to recover identified overpayments, performing a follow-up review to ensure that the claims were adjusted correctly, resulting in expected recovery.

4.    Perform claims system extracts and create reports, graphs, and charts to timely identify trends and patterns of potential healthcare fraud, waste and abuse.  Communicate findings to company management of various areas including provider relations, reimbursement etc.

5.    Calculate overpayments in established fraud, waste or abuse cases.  Identify all fraudulent activity included in the case, determine what lines of business were involved in the fraudulent activity, and measure overpayment by means of sampling or complete review.  Negotiate settlements with providers.
6.    Serve as the subject matter expert on all questions pertaining to vendor agreements, coding issues and claim processing issues.  Maintain open lines of communication with the provider community to address issues and resolve problems quickly and efficiently and to explore additional audit opportunities.  Providing oversight and strategic direction in terms of the vendor’s case load.

7.    Maintain current case related information on all applicable case management tracking systems such as FICO and FIMS.

8    Senior consultant only
•    Maintain a relationship with law enforcement to serve as their primary contact for investigations.  Work with the various agencies on strategies for completing fraud investigations that maximize the likely –hood they are prosecuted.
9.    Other duties as assigned or requested.


III. QUALIFICATIONS:
Minimum
FIPR Senior Consultant:
•    Bachelor’s degree in Accounting, Finance, Business or closely related field
•    Two (2) years of experience working with law enforcement on fraud cases through civil or criminal prosecution

FIPR Consultant:

•    Bachelor’s degree in Accounting, Finance, Business or closely related field  

Preferred

•    Five (5) years of institutional pricing knowledge and experience
•    Certified Fraud Examiner (CFE)
•    Certified Professional Coder - Hospital (CPC-H)
•    Knowledge of medical terminology
•    Experience in processing BlueCard, Local and FEP claims
•    Experience in working with SAS
•    Two years of working for a law enforcement agency

Knowledge, Skills and Abilities 
•    Demonstrated proficiency in using Excel, Word, PowerPoint, and Access.
•    Demonstrated strong multi-tasking and organizational skills.
•    Demonstrated strong verbal and written communication skills.
•    Demonstrated proficiency in using OSCAR, INSINQ, ICIS, and COR.


IV. SCOPE OF RESPONSIBILITY  
Does this role supervise/manage other employees?     No         
If yes, indicate the number of direct reports:  

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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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