Senior Fraud Investigator & Program Lead

Highmark Health; Nashville (TN); On-site; USD 73,000 - 117,000; Full time

Job summary

Highmark Health seeks an experienced anti-fraud professional to develop and maintain a comprehensive fraud program. You will conduct investigations into provider, member, and organizational activities, interview involved parties, and coordinate data extracts to deter improper payments across the enterprise.

You will testify when required, guide investigators, and lead special projects while ensuring compliance with HIPAA and state regulations.

Qualifications

• Bachelor’s degree or higher in a related field; substitutions noted.
• Experience in health insurance fraud investigations preferred.
• Certified fraud and coding credentials are advantageous.

Responsibilities

• Investigate potential provider/member fraud, waste, and abuse.
• Coordinate data extracts from multiple databases and support regulatory compliance.
• Develop and maintain annual anti-fraud program, training, and reporting.
• Provide subject- matter guidance to investigators and train team members.
• Engage with law enforcement and regulators as needed; support recovery of funds.

Skills

Fraud investigations

Data analysis

Interviews

Communication

Audit coordination

Regulatory knowledge

Education

Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or related field

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

Certified Fraud Examiner (CFE)

Certified Professional Coder (CPC)

Certified Outpatient Coder (COC)

Accredited Healthcare Fraud Investigator (AHFI)

6 years of related experience in lieu of Bachelor's

Job description

Highmark Health seeks an experienced anti-fraud professional to develop and maintain a comprehensive fraud program. You will conduct investigations into provider, member, and organizational activities, interview involved parties, and coordinate data extracts to deter improper payments across the enterprise.

You will testify when required, guide investigators, and lead special projects while ensuring compliance with HIPAA and state regulations.