Healthcare Fraud Investigator & Forensic Auditor

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

Job summary

Highmark Inc. seeks an anti-fraud investigator to develop and maintain an anti-fraud program, conduct investigations of fraud, waste and abuse, and coordinate with law enforcement.

The role involves fieldwork, interviews, and testimony in court, with a focus on reducing improper payments and ensuring regulatory compliance. Required are a Bachelor's degree or 6 years related experience, plus 3 years in health insurance fraud investigations; CFE/CPC/AHFI certifications are preferred.

Qualifications

• Requires degree or equivalent experience in health-related field and fraud investigations.
• Experience in health insurance fraud investigations preferred.
• Knowledge of HIPAA and regulatory requirements is a plus.

Responsibilities

• Investigate potential and existing fraud, waste and abuse activities across providers and members.
• Develop and maintain anti-fraud program, including training and annual fraud plans.
• Coordinate data extracts and work with law enforcement and regulatory agencies.
• Conduct field investigations and support recovery/savings of misappropriated funds.
• Provide advisory support to internal and external stakeholders.

Skills

Claims processing

Health insurance knowledge

Data mining tools

Communication skills

Written communication

Relationship building

Business acumen

Self-motivation

Strategic thinking

Problem solving

Education

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

6 years of related experience in lieu of Bachelor's

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

Tools

Fraud data mining tools

Claims processing systems

Job description

Highmark Inc. seeks an anti-fraud investigator to develop and maintain an anti-fraud program, conduct investigations of fraud, waste and abuse, and coordinate with law enforcement.

The role involves fieldwork, interviews, and testimony in court, with a focus on reducing improper payments and ensuring regulatory compliance. Required are a Bachelor's degree or 6 years related experience, plus 3 years in health insurance fraud investigations; CFE/CPC/AHFI certifications are preferred.