Senior Fraud Investigator & Program Lead

Highmark; United States; On-site; USD 73,000 - 117,000; Full time

Job summary

Highmark Inc. seeks a dedicated anti-fraud professional to develop and maintain an enterprise fraud program. You will conduct investigations of fraud, waste, and abuse across providers, members, facilities, pharmacies, and staff, and coordinate with law enforcement as needed.

The role requires expertise in audits, data extraction, and testimony in court, with leadership responsibilities for training and mentoring team members. On-site work with travel may be involved.

Qualifications

• Bachelor's degree or 6 years related experience required.

Responsibilities

• Perform investigations into potential and existing fraud, waste and abuse activities involving providers, members, facilities, pharmacies, groups and employees.
• Coordinate data extracts from multiple databases to identify improper payments and forward cases to appropriate committees or authorities.
• Develop and maintain annual anti-fraud program including training, fraud awareness and annual fraud plans/reports.

Skills

Fraud investigations

Data mining tools

Regulatory compliance

Court testimony

Communication skills

Project leadership

Attention to detail

Education

Bachelor's degree in accounting/finance/business/admin/IT or related

6 years related experience in lieu of degree

Master's degree in fraud/forensics or related field

Tools

Claims processing systems

Fraud data mining tools

Job description

Highmark Inc. seeks a dedicated anti-fraud professional to develop and maintain an enterprise fraud program. You will conduct investigations of fraud, waste, and abuse across providers, members, facilities, pharmacies, and staff, and coordinate with law enforcement as needed.

The role requires expertise in audits, data extraction, and testimony in court, with leadership responsibilities for training and mentoring team members. On-site work with travel may be involved.