Senior Fraud Investigator & Project Lead

Highmark; Pittsburgh (Allegheny County); On-site; USD 90,000 - 130,000; Full time

Job summary

Highmark Inc. is seeking an experienced professional to develop and maintain an anti-fraud program, including training and filing of Fraud Plans and Reports.

The role conducts investigations into fraud, waste and abuse by providers, members, facilities, and employees, with potential court testimony and coordination with law enforcement. The incumbent will lead field investigations, testify in court when required, and ensure compliance with internal audits and regulatory requirements.

Qualifications

• Bachelor’s degree requirement or 6 years of related experience in lieu of a degree.
• Master’s degree preferred for advanced fraud analytics.
• Experience in healthcare fraud investigations is required.
• Proven ability to lead projects and analyze financial data in health insurance settings.

Responsibilities

• Performs investigations into provider, member fraud, waste and abuse activities.
• Coordinates data extracts and forwards case to committees and law enforcement as needed.
• Develops and maintains the annual anti-fraud program including training and annual fraud plans.
• Provides advisory support to internal/external law enforcement and regulatory agencies.

Skills

Provider billing knowledge

Claims processing

Coding & billing

Communication skills

Data mining tools

Mentoring/training

Education

Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT or related field

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

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

Job description

Highmark Inc. is seeking an experienced professional to develop and maintain an anti-fraud program, including training and filing of Fraud Plans and Reports.

The role conducts investigations into fraud, waste and abuse by providers, members, facilities, and employees, with potential court testimony and coordination with law enforcement. The incumbent will lead field investigations, testify in court when required, and ensure compliance with internal audits and regulatory requirements.