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Job Description

Job Title: Fraud and Abuse Specialist
Job ID: 621183426
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:
UPMC Health Plan's Fraud Waste and Abuse Department is seeking a Fraud and Abuse Specialist! 


The Fraud and Abuse Specialist investigates all allegations of health care fraud and/or abuse against UPMC Health Plan, specifically the Community Health Choices Program. 


Per healthchoices.pa.gov: COMMUNITY HEALTHCHOICES (CHC) is Pennsylvania’s mandatory managed care program for dually eligible individuals and individuals with physical disabilities — serving more people in communities, giving them the opportunity to work, spend more time with their families, and experience an overall better quality of life. CHC has improved services for hundreds of thousands of Pennsylvanians.

Responsibilities:

  • 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.
  • Maintain database of investigative activity that should include names, addresses, identifying information regarding all parties in the investigation, and the documents in the file.
  • Act as a liaison with key internal contacts in the investigation and prosecution of insurance F&A.
  • Testify in a court of law as needed and participate in coordinating subrogation, reimbursement, and restitution matters.
  • 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 investigation files of evidence collected or received including claims, check in payment of claims, and other documents submitted in support of alleged fraud.

Qualifications

  • Bachelor's degree in a related field (or equivalent years of experience) required.
  • Three (3) 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/Disability/Veteran

Salary Range: $23.75 to $41.09 / hour

Union Position: No

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