Associate Fraud Analyst
Location: Camp Hill, Pennsylvania
Description: Highmark is currently seeking to employ Associate Fraud Analyst right now, this job will be dwelled in Pennsylvania. For complete informations about this job opportunity kindly read the description below. This position is responsible for conducting reviews of alleged fraud, waste and abuse (FWA) perpetrated by providers, members, facilities, pharmacies, groups and/or employees of the orga! nization. The initial responsibility of this position is to gather information related to a potential FWA allegation and apply analytical skills to determine the approach which will maximize financial recoveries for Highmark and/or protect Highmark members. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. This position is also responsible for the field investigative work necessary to complete a review of a special project, potential fraud, waste, or 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.
Essential Responsibilities:
1. Conducts financial, clinical and fraud investigations of both internal and external pa! rties using department case protocol, interview and data gathe! ring techniques and analytical skills.
Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark.
Determines the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctors' agreements, contract, etc.
Coordinates data extracts by assessing multiple databases both internally and externally.
Utilize analytical skills to determine appropriate investigative approach that will maximize financial recoveries and/or protect members. Present proposed approach to team lead or management.
Interviews providers, members or any other individual(s) necessary to complete a case review or special project.
Takes action to prevent further improper payments including recommendations for medical or reimbursement policy enhancements. Establish system flags ! to stop provider payments when appropriate.
Maintain all case documentation in sufficient detail to support investigation conclusions, provider inquiries, court proceedings and other law enforcement activities.
Forwards case to the Credentialing and/or Medical Review Committee, law enforcement and regulatory agencies.
COMPLEXITY OF CASES ASSIGNED VARIES BY LEVEL OF ANALYST. ASSOCIATE ANALYST POSITIONS REQUIRE INTERACTION WITH LEAD OR MANAGEMENT POSITIONS FOR APPROVAL OF INVESTIGATION STRATEGIES ON EACH CASE.
2. Provides support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee. Includes working directly with FBI, US Attorneys, District Attorney investigators and various other investigative bodies. In certain instances this may include testifying in support of a law enforcement case or to support any litigation involving Highmark.
Provides support as needed to var! ious Highmark departments in support of their provider contracting, net! work development or reimbursement initiatives. Participate in the development of annual facility audit plan.
3. Analyze results of investigations and determine appropriate negotiation strategies to maximize financial recoveries on behalf of Highmark, FEP, Medicare Advantage and ASO customers.
4. Communicate financial recovery and claim adjustment information to appropriate Finance and Operational areas.
5. Recommend Medical or Reimbursement policy changes based on results of investigations and information gathered from Provider interactions.
6. Provide detailed information to Regulatory bodies (including FEP, CMS and BCBSA) regarding FIPR investigations.
7. Work with Highmark clinical staff (Nurses, coders and Medical Directors) to review medical records and ascertain whether appropriate documentation exists to support the reimbursement. Work with external physician consultants to review clinical documentation when necessary.
8. Other duties as assigned or requested.
Highmark is an Affirmative Action/Equal Employment Opportunity (AA/EEO) employer.
Minimum Requirements:
Preferred Requirements:
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If you were! eligible to this job, please send us your resume, with salary requirements and a resume to Highmark.
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This job will be started on: Fri, 28 Jun 2013 02:12:29 GMT
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