Senior Fraud Investigator & Program Lead

Highmark Health; Pierre (SD); On-site; USD 79,000 - 127,000; Full time

Job summary

Highmark Inc. is seeking a seasoned investigator to develop and maintain an anti-fraud program, including training and annual fraud plans.

The role conducts investigations into potential fraud, waste, and abuse across providers, members, facilities, and employees, with interviews on-site or off-site. The position requires experience in health insurance fraud, strong leadership, and the ability to testify in court; you will coordinate with law enforcement and regulatory agencies and help recover

Qualifications

• 7 years in the Health Insurance industry and/or Healthcare Fraud investigations.
• 3 years of leading projects of varying size and complexity.

Responsibilities

• Monitor and coordinate investigative activities for the team.
• Serve as team lead and SME for Investigators; mentor others.
• Investigate potential and existing fraud, waste and abuse activities.
• Develop and maintain annual anti-fraud program including fraud training and annual fraud plans.
• Coordinate field investigations and support law enforcement and regulatory agencies.
• Deliver audit results and negotiate overpayments; recover misappropriated funds.

Skills

Provider payments

Claims processing

Coding & billing

Data analysis

Communication

Regulatory compliance

Problem solving

Team leadership

Education

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

6 years of related experience in lieu of Bachelor's

Master's Degree in Fraud/Forensics/Business or related field

Tools

Fraud data mining tools

Job description

Highmark Inc. is seeking a seasoned investigator to develop and maintain an anti-fraud program, including training and annual fraud plans.

The role conducts investigations into potential fraud, waste, and abuse across providers, members, facilities, and employees, with interviews on-site or off-site. The position requires experience in health insurance fraud, strong leadership, and the ability to testify in court; you will coordinate with law enforcement and regulatory agencies and help recover