Investigator at Highmark Health Juneau, AK

Job Summary

This role develops and maintains an anti‑fraud program, including training delivery, filing Fraud Plans and Reports, and conducting investigations into alleged fraud, waste, and abuse involving providers, members, facilities, pharmacies, groups, and employees. The investigator conducts interviews, performs field investigative work, prepares cases for referral to law enforcement, and coordinates recovery of misappropriated funds. The position also implements audits for proactive and investigative purposes to satisfy internal audit and regulatory requirements.

• Perform investigations into potential and existing provider and member fraud, waste, and abuse activities.
• Identify parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and employees.
• Conduct interviews with providers, members, or other individuals necessary to complete assigned investigations.
• Determine the scope of allegations or special projects by assembling necessary information, statistics, policies, procedures, licensure data, contracts, and agreements.
• Develop and maintain the annual anti‑fraud program, including facilitating fraud training, fraud awareness day, and filing annual fraud plans and reports per state regulations.
• Coordinate data extracts by assessing multiple internal and external databases.
• Take action to prevent further improper payments.
• Forward cases to the Credentialing and/or Medical Review Committee, law enforcement, and regulatory agencies.
• Complete necessary field investigative work for resolution of alleged fraud, waste, and abuse cases or special projects.
• Provide advisory support to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committees.
• Deliver audit results and manage over payment negotiations.
• Recover/sustain savings of misappropriated funds and work with Finance to ensure proper recording in financial statements.
• Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements, including contract, commission, surveillance, workers' compensation, and IME audits.
• Complete OFAC compliance audits to ensure payments are not made to unauthorized parties.
• Perform other duties as assigned or requested.

• Required Bachelor’s Degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field.
• Substitutions 6 years of related and progressive experience in lieu of a Bachelor’s degree.
• Preferred Master’s Degree in Fraud, Forensic Accounting, Business, or a related field.

• Required 3 years of relevant, progressive experience in the health insurance industry and/or healthcare fraud investigations.
• Preferred 1 year in financial analysis in an acute care hospital or health insurance setting.
• Preferred 1 year in professional billing, facility Patient Financial Services, HIM, Internal Audit, Professional/Facility Reimbursement, or Provider Contracting.

• Required None.
• Preferred Certified Fraud Examiner (CFE).
• Preferred Certified Professional Coder (CPC).
• Preferred Certified Outpatient Coder (COC).
• Preferred Accredited Healthcare Fraud Investigator (AHFI).

• Knowledge of provider facility payment methodology and claims processing systems.
• Proficiency in coding and billing.
• Understanding of technical and financial aspects of the health insurance industry.
• Strong computer skills, including experience with fraud/abuse data‑mining tools.
• Excellent written and oral communication skills.
• Strong relationship‑building and client‑focused skills.
• Self‑starter with the ability to work independently and as part of a team under pressure.
• Strategic thinking and proactive problem‑solving capabilities.

0% – 25%.

Includes lifting up to 50 pounds and occasional travel to field locations.

$57,700.00 – $.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.