Healthcare Fraud Investigator & Forensics Analyst

Highmark Health; Pennsylvania; Presencial; USD 63.000 - 97.000; Jornada completa

Descripción de la vacante

Highmark Inc. is seeking an anti-fraud professional responsible for developing and maintaining an anti-fraud program, conducting investigations into fraud, waste, and abuse, and coordinating with law enforcement and regulatory agencies.

The role includes field investigations, training delivery, and preparation of fraud plans and reports. Requirements include a Bachelor's degree in accounting/finance/business/IT or related field, 3 years in health insurance fraud investigations, and strong

Formación

• 3 years of relevant, progressive experience in health insurance or healthcare fraud investigations.
• Knowledge of provider facility payment methodology, claims processing and coding/billing.
• Strong written and oral communication skills; ability to testify in court when required.

Responsabilidades

• Performs investigations into potential and existing fraud, waste and abuse activities. Identifies involved parties and conducts interviews as needed.
• Develop and maintain annual anti-fraud program including training, fraud awareness, and annual fraud plans/reports.
• Coordinate data extracts by assessing multiple databases and forward cases to committees or law enforcement as needed.
• Complete field investigative work for resolution of fraud/waste and abuse cases or special projects.
• Provide advisory support to law enforcement/regulatory agencies and internal committees.
• Lead auditing efforts and assist in recovery/savings of misappropriated funds; work with Finance on financial statements.

Conocimientos

Fraud investigations

Interviewing

Communication skills

Data analysis

Attention to detail

Educación

Bachelor's degree in Accounting/Finance/Business Admin/Nursing/IT

Substitution: 6 years related experience

Master's degree preferred (Fraud/Forensics)

Descripción del empleo

Highmark Inc. is seeking an anti-fraud professional responsible for developing and maintaining an anti-fraud program, conducting investigations into fraud, waste, and abuse, and coordinating with law enforcement and regulatory agencies.

The role includes field investigations, training delivery, and preparation of fraud plans and reports. Requirements include a Bachelor's degree in accounting/finance/business/IT or related field, 3 years in health insurance fraud investigations, and strong