Healthcare Fraud Investigator

Highmark Health; Baton Rouge (LA); On-site; USD 63,000 - 97,000; Full time

Job summary

Highmark Inc. seeks an experienced anti-fraud investigator to develop and maintain an enterprise fraud program, deliver training, and file fraud plans and reports. You will conduct investigations into fraud, waste and abuse across providers, members, facilities, pharmacies, groups, and employees, and may testify in court.

Field investigations and coordination with law enforcement are required. You will perform audits, support regulatory compliance, and help recover misappropriated funds while

Qualifications

• Bachelor's degree or 6 years of related progressive experience in lieu of degree.
• 3 years of relevant, progressive experience in health insurance or healthcare fraud investigations.
• Certification in Fraud related fields preferred (not required).

Responsibilities

• Investigate potential and existing fraud, waste, and abuse activities across providers, members, facilities, pharmacies, groups, and employees.
• Develop and maintain the annual anti-fraud program, including training and annual fraud plans/reports.
• Coordinate data extracts from multiple databases to prevent improper payments and forward cases to regulatory bodies.

Skills

Provider payment methodology

Claims processing systems

Coding and billing proficiency

Fraud data mining tools

Excellent communication skills

Written and oral communication

Relationship building

Strategic thinking

Problem-solving

Education

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

6 years related experience in lieu of Bachelor's

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

Tools

Fraud data mining tools

Job description

Highmark Inc. seeks an experienced anti-fraud investigator to develop and maintain an enterprise fraud program, deliver training, and file fraud plans and reports. You will conduct investigations into fraud, waste and abuse across providers, members, facilities, pharmacies, groups, and employees, and may testify in court.

Field investigations and coordination with law enforcement are required. You will perform audits, support regulatory compliance, and help recover misappropriated funds while