Fraud Investigator: Forensics & Compliance

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

Job summary

Highmark Inc. seeks an experienced fraud investigations professional to develop and maintain a comprehensive anti-fraud program, including training and filing of plans and reports.

The role involves conducting investigations of fraud, waste, and abuse across providers, members, facilities, and staff, with interviews onsite or offsite. You will coordinate data extracts, support law enforcement, and lead audits to ensure regulatory compliance, including OFAC checks and recovery of misappropriated

Qualifications

• Bachelor's degree required or 6 years of related experience in lieu of degree.
• Preferred: Master’s in Fraud, Forensics Accounting, Business or related field.

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 and reports.
• Coordinates data extracts by assessing multiple databases; forwards cases to relevant committees and agencies.
• Conducts field investigative work for resolution of fraud/waste cases or special projects.
• Provides advisory support to law enforcement and regulatory agencies.
• Engages in audit results delivery and overpayment negotiations; supports recovery of misappropriated funds.
• Conducts audits to comply with internal audits and regulatory requirements; OFAC compliance.

Skills

Fraud investigations

Interviews & testimony

Data mining tools

Communication skills

Audit & compliance

Relationship building

Problem solving

Team work under pressure

Education

Bachelor's degree in Accounting/Finance/Business Admin/Nursing/IT or related field

6 years of related experience in lieu of Bachelor's degree

Tools

Fraud data mining tools

Claims processing systems

Job description

Highmark Inc. seeks an experienced fraud investigations professional to develop and maintain a comprehensive anti-fraud program, including training and filing of plans and reports.

The role involves conducting investigations of fraud, waste, and abuse across providers, members, facilities, and staff, with interviews onsite or offsite. You will coordinate data extracts, support law enforcement, and lead audits to ensure regulatory compliance, including OFAC checks and recovery of misappropriated