Healthcare Fraud Investigator & Anti-Fraud Program Lead

Highmark Health; Pittsburgh (Allegheny County); Presencial; USD 85.000 - 110.000; Jornada completa

Descripción de la vacante

Highmark Health in Pittsburgh seeks an experienced fraud investigator to develop and maintain an anti-fraud program, conduct investigations of suspected fraud, waste and abuse, and support regulatory reporting.

You will interview providers and members, coordinate with law enforcement, and help recover misappropriated funds while ensuring compliance with HIPAA and internal policies. Travel up to 25% may be required.

Formación

• Requires Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or related field
• Substitutions: 6 years of related and progressive experience in lieu of Bachelor's degree
• Preferred Master’s in Fraud, Forensics Accounting, Business or related field

Responsabilidades

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities.
• Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees.
• Conducts interviews with providers, members or other individuals to complete investigations.
• Develops and maintains annual anti-fraud program including training and annual fraud plans and reports.

Conocimientos

Fraud investigations

Data mining tools

Communication skills

Interviews

Court testimony

Regulatory compliance

Educación

Bachelor's degree in Accounting/Finance/Business

Master's degree preferred

Herramientas

Fraud data mining tools

Descripción del empleo

Highmark Health in Pittsburgh seeks an experienced fraud investigator to develop and maintain an anti-fraud program, conduct investigations of suspected fraud, waste and abuse, and support regulatory reporting.

You will interview providers and members, coordinate with law enforcement, and help recover misappropriated funds while ensuring compliance with HIPAA and internal policies. Travel up to 25% may be required.