Senior Investigator

Highmark Health

Multiple Locations, US
Base: $72,700.00 - $116,600.00; bonus/equity: not ...
Onsite
Provider and member fraud investigations
Conduct interviews with providers and members
Assemble necessary information and statistics
The incumbent is 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

  • The incumbent is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports.
  • The incumbent is 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.
  • Must be able to testify in a court of law, prepare cases for referral to various federal, state and local law enforcement entities and work with those agencies through closure of the case.

Matching Summary

The incumbent is 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: $72,700.00 - $116,600.00; Bonus/Equity: Not specified; Benefits: Not specified

Skills & Requirements

Must-have

  • Provider and member fraud investigations
  • Conduct interviews with providers and members
  • Assemble necessary information and statistics
  • Coordinate data extracts from multiple databases
  • Prevent further improper payments
  • Deliver audit results and overpayment negotiations

Nice-to-have

  • Subject matter expert for investigators
  • Guidance and training for team members
  • Project lead for special projects
  • Client focused with strong business acumen
  • Innovative problem-solving capabilities

Key Requirements

  • 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
  • 5 years in Health insurance industry and/or Healthcare fraud investigations
  • 1 year of leading projects
  • Certified Fraud Examiner (CFE)
  • Certified Professional Coder (CPC)
  • Certified Outpatient Coder (COC)
  • Accredited Healthcare Fraud Investigator (AHFI)

Work Rights

Not specified

Tailored Resume

Cover Letter