Fraud Investigation & Compliance Specialist

Highmark; United States; On-site; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking a position responsible for developing and maintaining an anti-fraud program, including training delivery and filing of Fraud Plans and Reports.

The role involves conducting investigations into fraud, waste, and abuse by providers, members, facilities, pharmacies, groups and employees, with interviews conducted on-site or off-site. The incumbent must testify in court, prepare cases for referral to law enforcement, and collaborate with agencies to close cases.

Qualifications

• Bachelor's degree or 6 years of related experience in healthcare fraud investigations.
• 3 years of relevant experience in health insurance industry and/or healthcare fraud investigations.
• Preferred certifications in fraud and coding are advantageous.

Responsibilities

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities.
• Develop and maintain annual anti-fraud program including fraud training and annual fraud plans/reports.
• Coordinate data extracts from multiple databases to identify improper payments and forward cases to relevant committees or law enforcement.
• Provide advisory support to internal and external law enforcement and regulatory agencies.

Skills

Fraud investigations

Health insurance

Data mining tools

Strong communication

Court testimony

Education

Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or related field

6 years related experience in lieu of Bachelor's

Tools

Claims processing systems

Fraud data mining tools

Job description

Highmark Inc. is seeking a position responsible for developing and maintaining an anti-fraud program, including training delivery and filing of Fraud Plans and Reports.

The role involves conducting investigations into fraud, waste, and abuse by providers, members, facilities, pharmacies, groups and employees, with interviews conducted on-site or off-site. The incumbent must testify in court, prepare cases for referral to law enforcement, and collaborate with agencies to close cases.