Fraud Analyst

Allegheny Health Network Pittsburgh , PA 15201

Posted 5 months ago

Company :Highmark IncJob Description :


The incumbent is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. This position 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. 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. 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.

1.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
2.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.
    3.Completes all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.
    4.Provides support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
    5.Recover misappropriated funds paid by Highmark and affiliated companies and work with Finance to ensure proper recording the financial statements.
    6.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. In addition, this position will complete Office of Foreign Asset Control (OFAC) to ensure payments are not issued to unauthorized parties.
    7.Other duties as assigned or requested.


Education, Licenses/Certifications, and Experience


  • A High School Diploma/GED
  • 3-5 years of relevant, progressive experience in the area of specialization. Grandfathered experience requirements effective August 2016.


  • 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 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.


Does this role supervise/manage other employees?



Is Travel Required?


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 (

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

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Detection & Investigation Analyst

PNC Bank

Posted 3 days ago

VIEW JOBS 7/13/2019 12:00:00 AM 2019-10-11T00:00 Position Overview At PNC, our people are our greatest differentiator and competitive advantage in the markets we serve. We are all united in delivering the best experience for our customers. As a Detection & Investigation Analyst within PNC's Reg E organization, you will be based in Pittsburgh, PA at the Firstside Center Building. Job Description * Participates in reviewing and investigating customer cases, reports, and work for potential and actual loss; minimizes fraud, AML and/or organizational risk. Responsible for early detection of suspicious activity, control and prevention of losses. * Under supervision, researches and analyzes bank activities and reports to detect and prevent possible fraudulent and illegal activities. Escalates issues as appropriate. * Uses defined research procedures to identify and resolve issues. * Follows standards and practices to mitigate fraud, AML and other risk exposure and loss. * Prepares and maintains appropriate documentation of analysis performed and coordinates with internal or external stakeholders as appropriate. PNC Employees take pride in our reputation and to continue building upon that we expect our employees to be: * Customer Focused - Knowledgeable of the values and practices that align customer needs and satisfaction as primary considerations in all business decisions and able to leverage that information in creating customized customer solutions. * Managing Risk - Assessing and effectively managing all of the risks associated with their business objectives and activities to ensure they adhere to and support PNC's Enterprise Risk Management Framework. Competencies Anti-money Laundering/Sanctions Policies and Procedures – Knowledge of and ability to prevent or report money laundering and Sanctions-related activities in banking and financial services industry. Anti-money Laundering/Sanctions Policies and Procedures – Knowledge of and ability to prevent or report money laundering and Sanctions-related activities in banking and financial services industry. Business Process Improvement – Knowledge of and ability to use methods for identifying, evaluating, introducing and implementing more efficient approaches to performing business related activities. Decision Making and Critical Thinking – Understanding of the issues related to the decision-making process; ability to analyze situations fully and accurately, and reach productive decisions. Effective Communications – Understanding of effective communication concepts, tools and techniques; ability to effectively transmit, receive, and accurately interpret ideas, information, and needs through the application of appropriate communication behaviors. Fraud Detection and Prevention – Knowledge of and ability to utilize processes, tools, and techniques for detecting, addressing and preventing fraudulent situations. Information Capture – Knowledge of the processes and the ability to identify, capture and document relevant business information in an auditable, organized, understandable and easily retrievable manner. Operational Risk – Knowledge of policies and processes for operational risk management; ability to use tools, data, and best practices to identify, assess, and manage operational risk exposures. Problem Solving – Knowledge of approaches, tools, techniques for recognizing, anticipating, and resolving organizational, operational or process problems; ability to apply this knowledge appropriately to diverse situations. Standard Operating Procedures – Knowledge of and ability to design, implement and evaluate standard operating procedures affecting daily and strategic business operations in order to increase operational efficiency. Work Experience Roles at this level typically do not require a university / college degree, but do require related experience or product knowledge to accomplish primary duties. Typically requires 1+ years of related experience. In lieu of a degree, a comparable combination of education and experience (including military service) may be considered. Education No Degree (Required) Disability Accommodations Statement: The PNC workplace is inclusive and supportive of individual needs. If you have a physical or other impairment that might require an accommodation, including technical assistance with the PNC Careers website or submission process, please call 877-968-7762 and select Option 4: Recruiting or contact us via email at The Human Resources Service Center hours of operation are Monday - Friday 9:00 AM to 5:00 PM ET. Equal Employment Opportunity (EEO): PNC provides equal employment opportunity to qualified persons regardless of race, color, sex, religion, national origin, age, sexual orientation, gender identity, disability, veteran status, or other categories protected by law. PNC Bank Pittsburgh PA

Fraud Analyst

Allegheny Health Network