Fraud Investigator & Anti-Fraud Program Lead

Highmark Health; Ohio; Presencial; USD 63.000 - 97.000; Jornada completa

Descripción de la vacante

Highmark Inc. is seeking a seasoned investigator to develop and maintain an anti-fraud program, conduct investigations into provider/member fraud, waste, and abuse, and coordinate with law enforcement.

The role requires interviews, field investigations, and the ability to testify in court while staying compliant with internal and regulatory requirements. The candidate should have a Bachelor’s degree in a related field, 3 years of relevant healthcare fraud experience, and strong data mining and

Formación

• Bachelor's degree in accounting, finance, business administration, nursing, IT or related field.
• 6 years of related and progressive experience in lieu of Bachelor's degree.
• Master's degree in Fraud, Forensics Accounting, Business or related field (preferred).
• 3 years of relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations (required).
• Certified Fraud Examiner (CFE) or AHFI (preferred).

Responsabilidades

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities.
• Develop and maintain annual anti-fraud program including training and annual fraud plans and reports.
• Coordinate data extracts from multiple databases and forward cases to law enforcement and regulatory agencies.
• Conduct field investigations for resolution of fraud/waste and abuse cases.
• Provide advisory support to law enforcement and regulatory agencies as needed.
• Engage in audit results delivery and recovery/savings of misappropriated funds.

Conocimientos

Billing knowledge

Fraud investigations

Data mining tools

Communication skills

Problem solving

Teamwork

Strategic thinking

Educación

Bachelor's degree in a relevant field

Herramientas

Data mining software

Descripción del empleo

Highmark Inc. is seeking a seasoned investigator to develop and maintain an anti-fraud program, conduct investigations into provider/member fraud, waste, and abuse, and coordinate with law enforcement.

The role requires interviews, field investigations, and the ability to testify in court while staying compliant with internal and regulatory requirements. The candidate should have a Bachelor’s degree in a related field, 3 years of relevant healthcare fraud experience, and strong data mining and