Senior Healthcare Fraud Investigator & Program Lead

Highmark Health; Phoenix (AZ); On-site; USD 73,000 - 117,000; Full time

Job summary

Highmark Health seeks an experienced professional to develop and maintain an anti-fraud program, conduct investigations into fraud, waste and abuse by providers, members, facilities and employees, and coordinate with law enforcement as needed.

The role requires leading projects, conducting interviews, and testifying in court while ensuring compliance with internal audits and state regulations.

Qualifications

• Bachelor's degree or 6 years of related experience required.
• 5 years in the Health insurance industry and/or Healthcare fraud investigations.
• 1 year of leading projects of varying size and complexity.
• Certified Fraud Examiner (CFE) preferred

Responsibilities

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities.
• Coordinates data extracts by assessing multiple databases both internally and externally.
• Develop and maintain annual anti-fraud program including fraud training and annual fraud plans.
• Will testify in court and coordinate with law enforcement and regulatory agencies.

Skills

provider payments

claims processing

coding and billing

fraud investigations

data mining tools

communication skills

team leadership

problem solving

Education

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

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

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

Job description

Highmark Health seeks an experienced professional to develop and maintain an anti-fraud program, conduct investigations into fraud, waste and abuse by providers, members, facilities and employees, and coordinate with law enforcement as needed.

The role requires leading projects, conducting interviews, and testifying in court while ensuring compliance with internal audits and state regulations.