Senior Fraud Analyst-2

Job ID: J118925
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Mar 9, 2018

Share:

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 reviews 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 reviews and coordinating the recovery 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

  • 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
  • Conduct reviews of areas or programs as requested both internally and externally using department case protocol.
  • Identify parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries.
  • Interview providers, members or any other individual(s) necessary to complete a case review or special project.
  • Determine the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctors’ agreements, contract, etc.
  • Coordinate data extracts by assessing multiple databases both internally and externally.
  • Take action to prevent further improper payments.
  • Forward case to the Credentialing and/or Medical Review Committee, law enforcement and regulatory agencies.
  • Complete all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.
  • Provide support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
  • Recover misappropriated funds paid by the Organization 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. 
  • Complete Office of Foreign Asset Control (OFAC) to ensure payments are not issued to unauthorized parties.
  • Other duties as assigned or requested.

QUALIFICATIONS

Minimum

  • A High School Diploma/GED
  • 5-10 years of relevant, progressive experience in the area of specialization

Preferred

  • Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT or closely related field.
  • 2 years financial analysis experience in acute care hospital or health insurance setting.
  • Experience in hospital Patient Financial Services, HIM, Internal Audit, Reimbursement or Contracting departments preferred.
  • FCLS fraud claims law specialist
  • Certified Fraud Examiner (CFE)

Knowledge, Skills and Abilities  

  • 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

set forth in the code of business conduct and company policies

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

Share:

Interested in working at the Highmark Health enterprise?
Take the first step by joining our Talent Network today!

Join Our Talent Network

Similar Jobs

Assoc Fraud Analyst

Pittsburgh, PA, United States
Audit & Compliance

Fraud Analyst

Pittsburgh, PA, United States
Audit & Compliance

Senior Internal Audit Analyst

Pittsburgh, PA, United States
Audit & Compliance

Quality Assurance Analyst - Audit-2

Wilmington, DE, United States
Audit & Compliance

Senior Compliance Auditor

Pittsburgh, PA, United States
Audit & Compliance

Senior Compliance Analyst

Pittsburgh, PA, United States
Audit & Compliance

Compliance Consultant - Medicaid

Charleston, WV, United States
Audit & Compliance

Associate IT Audit Analyst

Pittsburgh, PA, United States
Audit & Compliance

Manager: Compliance & Business Transformation

Pittsburgh, PA, United States
Audit & Compliance

Compliance Auditor

Pittsburgh, PA, United States
Audit & Compliance

Fraud Analyst - Pharmacy

Pittsburgh, PA, United States
Audit & Compliance

Internal Audit Analyst

Pittsburgh, PA, United States
Audit & Compliance

Manager Compliance Audit

Pittsburgh, PA, United States
Audit & Compliance

Senior Compliance Analyst - Medicaid

Charleston, WV, United States
Audit & Compliance

Sr Compliance Analyst

Pittsburgh, PA, United States
Audit & Compliance

Mgr, Government Compliance

Little Rock, AR, United States
Audit & Compliance

Compliance Analyst - GHP

Pittsburgh, PA, United States
Audit & Compliance

Compliance Auditor

Pittsburgh, PA, United States
Audit & Compliance

Assoc IT Audit Analyst

Pittsburgh, PA, United States
Audit & Compliance

Director Medicare Compliance

Pittsburgh, PA, United States
Audit & Compliance

Physician Coding Auditor

Erie, PA, United States
Audit & Compliance