Fraud Investigator - Health Plan Compliance & Audits

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

Job summary

Highmark Inc. seeks an experienced anti-fraud professional to develop and maintain a comprehensive fraud program, conduct investigations, and coordinate regulatory interactions. You will train staff, file annual fraud plans and reports, and ensure compliance with HIPAA and policy requirements.

The role requires ability to testify in court, coordinate externally with agencies, and lead recovery efforts for misappropriated funds, with field investigations and audits as core duties.

Qualifications

• Bachelor's degree in accounting, finance, business, nursing, IT or related field.
• 3 years of relevant, progressive experience in health insurance and/or healthcare fraud investigations.
• Preferred certifications: CFE, CPC, COC, AHFI.
• Substitution: 6 years of related experience in lieu of a Bachelor's degree.
• Strong written and oral communication, and analytical abilities.

Responsibilities

• Investigate potential and existing provider and member fraud, waste and abuse activities.
• Develop and maintain the anti-fraud program, including training and annual fraud plans/reports.
• Coordinate data extracts from multiple databases and liaise with law enforcement/regulatory agencies.
• Conduct field investigations and assist in recovery/savings of misappropriated funds.
• Provide advisory support to internal/external agencies and committees.
• Audit results delivery and support for overpayment negotiations.

Job description

Highmark Inc. seeks an experienced anti-fraud professional to develop and maintain a comprehensive fraud program, conduct investigations, and coordinate regulatory interactions. You will train staff, file annual fraud plans and reports, and ensure compliance with HIPAA and policy requirements.

The role requires ability to testify in court, coordinate externally with agencies, and lead recovery efforts for misappropriated funds, with field investigations and audits as core duties.