Fraud Investigator & Anti-Fraud Program Specialist

Highmark Health; Vermont; On-site; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. is seeking an experienced anti-fraud professional to develop and maintain a comprehensive fraud program. You will conduct investigations across providers, members, facilities, and vendors, prepare cases for law enforcement, and help ensure regulatory compliance through audits and reporting.

The role requires strong analytical, communication, and interview skills, with fieldwork and testimony in court as potential duties. This position is office-based with periodic travel as needed.

Qualifications

• Bachelor's degree or 6 years related experience required.
• Master's degree preferred for advanced fraud investigations.

Responsibilities

• Investigate potential and existing fraud, waste and abuse activities among providers, members, facilities, pharmacies, groups and employees.
• Develop and maintain annual anti-fraud program including training and fraud awareness; file annual fraud plans/reports per state regulations.
• Coordinate data extracts from multiple databases; take action to prevent improper payments and refer cases to authorities as needed.
• Complete field investigations for resolution of fraud/waste and abuse cases or special projects.
• Advise internal/external law enforcement and regulatory agencies as needed.
• Conduct audits to comply with internal audit and regulatory requirements.
• Perform OFAC checks to ensure payments go to authorized parties.
• Other duties as assigned.

Skills

Provider payment method

Claims processing systems

Coding and billing proficiency

Health insurance knowledge

Fraud data mining

Excellent communication

Detail oriented

Relationship building

Strategic thinking

Problem solving

Team collaboration

Education

Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field

6 years of related experience in lieu of Bachelor's

Master's in Fraud, Forensics Accounting, Business or related field

Job description

Highmark Inc. is seeking an experienced anti-fraud professional to develop and maintain a comprehensive fraud program. You will conduct investigations across providers, members, facilities, and vendors, prepare cases for law enforcement, and help ensure regulatory compliance through audits and reporting.

The role requires strong analytical, communication, and interview skills, with fieldwork and testimony in court as potential duties. This position is office-based with periodic travel as needed.