Senior Fraud Investigator & Case Lead

Highmark Health; Dover (DE); On-site; USD 73,000 - 117,000; Full time

Job summary

Highmark Inc. is seeking an experienced investigator to develop and maintain an anti-fraud program, conduct investigations into potential fraud, waste, and abuse, and coordinate with law enforcement and regulatory agencies. The role includes interviews onsite or offsite and field work for special projects.

The position requires 5+ years in health insurance fraud investigations, ability to testify in court, and experience leading projects. Knowledge of HIPAA and compliance is essential.

Qualifications

• Bachelor's degree in accounting, finance, business administration, nursing, IT or related field; substitutions: 6 years of related experience in lieu of degree.
• 5 years in Health insurance industry and/or Healthcare fraud investigations.
• 1 year of leading projects of varying size and complexity.
• Certified Fraud Examiner (CFE) preferred.

Responsibilities

• Investigate potential and existing provider and member fraud, waste and abuse activities.
• Conduct interviews with providers, members, or other individuals as needed.
• Coordinate data extracts by assessing multiple databases.
• Develop and maintain the anti-fraud program including training and annual plans/reports.
• Provide advisory support to law enforcement and regulatory agencies.
• Support recovery/savings of misappropriated funds and audit outcomes.

Skills

Billing proficiency

Claims processing

Data mining tools

Communication skills

Relationship building

Analytical thinking

Education

Bachelor's degree or 6 years experience

Master's in Fraud / Forensics (preferred)

Job description

Highmark Inc. is seeking an experienced investigator to develop and maintain an anti-fraud program, conduct investigations into potential fraud, waste, and abuse, and coordinate with law enforcement and regulatory agencies. The role includes interviews onsite or offsite and field work for special projects.

The position requires 5+ years in health insurance fraud investigations, ability to testify in court, and experience leading projects. Knowledge of HIPAA and compliance is essential.