Job Description

Job Title: Fraud and Abuse Specialist
Job ID: 675192
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility: UPMC Health Plan
Department: Fraud, Waste & Abuse
Location: 600 Grant St, Pittsburgh PA 15219

Description

Purpose:
The Fraud and Abuse Specialist investigates all allegations of health care fraud and/or abuse against UPMC Health Plan.

 

This position is Monday- Friday daylight on the 5th floor of the Steel Tower

Responsibilities:

  • Act as a liaison with key internal contacts in the investigation and prosecution of insurance F&A.
  • Act as a liaison with the DPW, BPI, CMS, PID, the IFPA, local, county, state, and federal law enforcement agencies, and all other relevant regulatory oversight agencies,
  • Maintain database of investigative activity that should include names, addresses, identifying information regarding all parties in the investigation, and the documents in the file.
  • Maintain investigation files of evidence collected or received including claims, check in payment of claims, and other documents submitted in support of alleged fraud.
  • Perform investigations and/or audits resulting from fraud and abuse (F&A) referrals. Reviews include, but are not limited to, providers and vendors regarding business issues such as claims, marketing, underwriting, and other circumstances of suspected F&A which, upon investigation, give evidence that a violation may have occurred.
  • Testify in a court of law as needed and participate in coordinating subrogation, reimbursement, and restitution matters.

Qualifications

  • Bachelors degree in a related field (or equivalent years of experience) required.
  • Three years of experience in health insurance, preferably in a fraud and abuse investigative capacity required.
  • Experience should include claims processing, coding, auditing, underwriting, and/or information systems.

    Licensure, Certifications, and Clearances:
    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $22.60 to $39.11

Union Position: No

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