Job Description :
This potential candidate is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports.

A High School Diploma/GED is required for all levels.
Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT or closely related field.
Two (2) years financial analysis experience in acute care hospital or health insurance setting.
Experience in hospital Patient Financial Services, HIM, Internal Audit, Reimbursement Contracting departments preferred.
FCLS fraud claims law specialist
Certified Fraud Examiner (CFE)

This position 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.
Conducts reviews of areas or programs as requested both internally and externally using department case protocol.
Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries.
Interviews providers, members or any other individual(s) necessary to complete a case review 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.
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.

Provides support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.