Fraud Investigator – Health Insurance & Forensics

Highmark Health; Pierre (SD); On-site; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. in the United States is seeking a senior anti-fraud professional responsible for developing and maintaining an anti-fraud program, delivering training, and filing Fraud Plans and Reports.

The role conducts investigations of fraud, waste, and abuse across providers, members, facilities, pharmacies, and employees, with field work and possible onsite or offsite interviews. The incumbent may testify in court and collaborate with law enforcement to recover misappropriated funds,

Qualifications

• 3 years of relevant health insurance fraud investigations experience.
• Bachelor’s degree or equivalent experience in related field.
• Knowledge of provider payment methodologies and claims processing.
• Ability to testify in court and coordinate with law enforcement.

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 and forwards cases to appropriate committees or agencies.
• Conduct audits and field investigations for proactive and investigative purposes to comply with internal audit and regulatory requirements.

Skills

Fraud investigations

Data mining

Communication skills

Documentation

Team collaboration

Strategic thinking

Regulatory knowledge

Attention to detail

Education

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

6 years related experience in lieu of Bachelor's degree

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

Job description

Highmark Inc. in the United States is seeking a senior anti-fraud professional responsible for developing and maintaining an anti-fraud program, delivering training, and filing Fraud Plans and Reports.

The role conducts investigations of fraud, waste, and abuse across providers, members, facilities, pharmacies, and employees, with field work and possible onsite or offsite interviews. The incumbent may testify in court and collaborate with law enforcement to recover misappropriated funds,