Senior Fraud Investigator & Compliance Lead

Highmark Health; Pierre (SD); On-site; USD 73,000 - 117,000; Full time

Job summary

Highmark Health is seeking a seasoned anti-fraud professional to develop and maintain a comprehensive anti-fraud program. You will conduct investigations of fraud, waste and abuse across providers, members, facilities, pharmacies, groups and employees, and testify when needed in court.

You will coordinate data extracts, lead training, and collaborate with law enforcement and regulatory agencies, while ensuring regulatory compliance and driving recoveries where appropriate.

Qualifications

• Bachelor's degree or equivalent in a related field. 5 years in Health insurance industry or healthcare fraud investigations.
• 6 years of related and progressive experience in lieu of Bachelor's degree available as substitution.
• Master's degree preferred in Fraud, Forensics or related field.

Responsibilities

• Investigate potential and existing provider, member, and staff fraud, waste and abuse activities in Highmark and Subsidiaries.
• Coordinate data extracts by assessing multiple databases to prevent improper payments.
• Develop and maintain annual anti-fraud program, including fraud training and annual plans/reports.
• Serve as subject matter expert for Investigators; provide guidance and mentor team members; lead special projects.
• Conduct field investigations and support law enforcement/regulatory agencies as needed.
• Deliver audit results and participate in recovery/savings of misappropriated funds.
• Ensure compliance with internal audit and regulatory requirements.
• Perform audits across contracts, commissions, surveillance, workers’ compensation and IME; OFAC compliance.

Skills

Provider payment methodology

Claims processing systems

Coding & billing proficiency

Health insurance knowledge

Fraud data mining tools

Communication skills

Relationship building

Self-starter / work under pressure

Strategic thinking

Problem-solving

Education

Bachelor's degree in Accounting, Finance, Business Admin, Nursing, IT or related field

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

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

Job description

Highmark Health is seeking a seasoned anti-fraud professional to develop and maintain a comprehensive anti-fraud program. You will conduct investigations of fraud, waste and abuse across providers, members, facilities, pharmacies, groups and employees, and testify when needed in court.

You will coordinate data extracts, lead training, and collaborate with law enforcement and regulatory agencies, while ensuring regulatory compliance and driving recoveries where appropriate.