Senior Fraud Investigator & Program Lead

Highmark Health; Nashville (TN); On-site; USD 79,000 - 127,000; Full time

Job summary

Highmark Inc. in Nashville, TN, is seeking a seasoned anti-fraud investigator to develop and maintain an anti-fraud program, conduct investigations across providers, members, facilities, pharmacies, groups and employees, and coordinate with law enforcement.

The role also involves testifying in court and preparing cases for referrals. You will lead investigations, train team members, oversee audits, and ensure compliance with HIPAA and regulatory requirements while driving recovery and savings

Qualifications

• Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field required.
• 6 years of related and progressive experience in lieu of Bachelor's degree accepted.
• Master's Degree in Fraud, Forensics Accounting, Business or related field preferred.

Responsibilities

• Monitor and coordinate investigative activities for the team.
• Serve as team lead and SME for Investigators and mentor others.
• Conduct investigations into potential fraud, waste and abuse activities across providers, members, facilities, pharmacies, groups and employees.

Skills

Provider payments knowledge

Communication skills

Self-motivation

Strategic thinking

Relationship building

Client focus

Computer skills

Problem-solving

Education

Bachelor's degree in related field

Master's degree (preferred)

Job description

Highmark Inc. in Nashville, TN, is seeking a seasoned anti-fraud investigator to develop and maintain an anti-fraud program, conduct investigations across providers, members, facilities, pharmacies, groups and employees, and coordinate with law enforcement.

The role also involves testifying in court and preparing cases for referrals. You will lead investigations, train team members, oversee audits, and ensure compliance with HIPAA and regulatory requirements while driving recovery and savings