Lead Investigator

Highmark Health

Working At Home, WV, United States
Base: $79,300.00 - $127,100.00; bonus/equity: not ...
Onsite
Provider and member fraud investigations
Conducting interviews
Developing anti-fraud programs
Responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports

Job Summary

  • Responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports.
  • Responsible for conducting investigations of organizational or functional activities related to alleged fraud, waste and abuse perpetrated by providers, members, facilities, pharmacies, groups and/or employees of the organizations and Subsidiaries.
  • Responsible for recovery/ savings of misappropriated funds paid by Highmark and affiliated companies and work with Finance to ensure proper recording the financial statements.

Matching Summary

Responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports.

Salary

Base: $79,300.00 - $127,100.00; Bonus/Equity: Not specified; Benefits: Not specified

Skills & Requirements

Must-have

  • Provider and member fraud investigations
  • Conducting interviews
  • Developing anti-fraud programs
  • Testify in court of law
  • Fraud, waste and abuse case management
  • Data mining tools proficiency

Nice-to-have

  • Strong relationship building skills
  • Client focused with strong business acumen
  • Self-starter with ability to work independently
  • Innovative problem-solving capabilities

Key Requirements

  • 7 years Health Insurance industry/Healthcare Fraud investigations
  • 3 years leading projects
  • Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field
  • 6 years related progressive experience in lieu of Bachelor's degree

Work Rights

Not specified

Tailored Resume

Cover Letter