Senior Fraud Investigations Lead

Highmark Health; Boston (MA); On-site; USD 79,000 - 127,000; Full time

Job summary

Highmark Inc. is seeking an experienced investigator to develop and maintain an anti-fraud program, conduct investigations of fraud, waste and abuse, and coordinate field work with providers, members, and facilities.

The role requires testifying in court and communicating with law enforcement and regulators. The candidate will lead investigations, train team members, and develop annual fraud plans and reports while staying updated on insurance laws and regulatory changes.

Qualifications

• Bachelor's degree required or 6 years of related experience in lieu of degree.
• Master's degree preferred in fraud/forensics or related field.
• 7 years in Health Insurance industry and/or Healthcare Fraud investigations required.

Responsibilities

• Lead investigations into provider and member fraud, waste and abuse.
• Coordinate field investigations and interviews with providers or members.
• Develop and maintain anti-fraud program including training and annual fraud plans/reports.
• Testify in court and coordinate with law enforcement and regulatory agencies.
• Conduct audits to comply with internal and regulatory requirements.

Skills

Provider payments

Claims processing

Coding & billing

Data mining tools

Communication skills

Relationship building

Problem solving

Independence

Strategic thinking

Court testimony

Education

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

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

6 years of related experience in lieu of Bachelor's degree

Tools

Fraud data mining tools

Job description

Highmark Inc. is seeking an experienced investigator to develop and maintain an anti-fraud program, conduct investigations of fraud, waste and abuse, and coordinate field work with providers, members, and facilities.

The role requires testifying in court and communicating with law enforcement and regulators. The candidate will lead investigations, train team members, and develop annual fraud plans and reports while staying updated on insurance laws and regulatory changes.