Fraud & Abuse Investigator

Highmark Health; Boston (MA); On-site; USD 95,000 - 130,000; Full time

Job summary

Highmark Inc. seeks an experienced anti-fraud professional to lead the development and maintenance of our fraud program and deliver training. The role conducts investigations across providers, members, facilities, and staff, and may involve onsite or offsite interviews.

You will coordinate with law enforcement and regulators, prepare cases for referral, and ensure compliance with internal audits and external requirements. Strong analytical and communication skills are essential.

Qualifications

• Bachelor’s degree in a related field required.
• Minimum 3 years of health insurance or healthcare fraud investigations.
• Master’s degree in Fraud or Forensics preferred.
• HIPAA knowledge and regulatory familiarity recommended.

Responsibilities

• Investigate potential and existing provider, member, and facility fraud.
• Conduct interviews with providers, members, or others as needed.
• Develop and maintain the anti-fraud program and train staff.
• Coordinate data extracts from multiple databases internal/external.
• Support law enforcement and regulatory agency coordination.
• Testify in court and prepare cases for referral when required.
• Perform audits to ensure internal and regulatory compliance.

Skills

Fraud investigations

Interviews

Audit coordination

Regulatory compliance

Court testimony

Data analysis

Communication skills

Project coordination

Education

Bachelor's degree in Accounting/Finance/BA/Related

6 years related experience in lieu of degree

Master's in Fraud/Forensics/Business

Tools

Fraud data mining tools

Claims processing systems

Office software

Job description

Highmark Inc. seeks an experienced anti-fraud professional to lead the development and maintenance of our fraud program and deliver training. The role conducts investigations across providers, members, facilities, and staff, and may involve onsite or offsite interviews.

You will coordinate with law enforcement and regulators, prepare cases for referral, and ensure compliance with internal audits and external requirements. Strong analytical and communication skills are essential.