Lead Investigator

About the Role

This position develops and maintains an anti-fraud program, including training delivery, fraud plan development, and regulatory reporting. The incumbent conducts investigations into alleged fraud, waste, and abuse by providers, members, facilities, pharmacies, groups, and/or employees of Highmark and its subsidiaries. Responsibilities include interviews (onsite or offsite), case preparation for law enforcement referrals, testimony in court, and coordination of recovery/savings related to fraud, waste, and abuse. The role also involves proactive and investigative audits to comply with internal and regulatory requirements.

Responsibilities

• Monitor and coordinate investigative activities for the team, serving as the initial point of contact for internal and external stakeholders.
• Act as team lead and subject matter expert, providing guidance, training, and mentorship to investigators.
• Lead special projects within the department.
• Investigate potential and existing provider and member fraud, waste, and abuse, identifying involved parties through reviews of inquiries and complaints.
• Conduct interviews with providers, members, or other individuals necessary to complete investigations or special projects.
• Determine the scope of allegations or projects by assembling relevant information, statistics, policies, procedures, licensure details, and contractual agreements.
• Develop and maintain the annual anti-fraud program, including facilitating fraud training, awareness initiatives, and filing annual fraud plans and reports in accordance with state regulations.
• Update knowledge of insurance laws annually, particularly regarding lines of business.
• Complete all necessary field investigative work to resolve alleged fraud, waste, and abuse cases or special projects.
• Provide advisory support to internal and external law enforcement, regulatory agencies, Credentialing, or Medical Review Committees.
• Deliver audit results and engage in overpayment negotiations, ensuring recovery/savings of misappropriated funds and proper financial recording.
• Conduct audits for proactive and investigative purposes, including contract, commission, surveillance, workers’ compensation, and Independent Medical Examinations (IME).
• Complete Office of Foreign Asset Control (OFAC) reviews to prevent payments to unauthorized parties.
• Coordinate data extracts from multiple internal and external databases to prevent improper payments and forward cases to relevant committees or agencies.
• For WV Medicaid: Initiate investigations, develop fraud, waste, and abuse (FWA) cases, follow up on program integrity leads, respond to Requests for Information (RFIs) from agencies like BMS and MFCU, and act as the point of contact for program integrity deconfliction.
• Participate in West Virginia-based training, task forces, and relevant meetings.

Requirements

• Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field. Six years of progressive, related experience may substitute for the degree.
• Seven years of experience in the health insurance industry and/or healthcare fraud investigations.
• Three years of experience leading projects of varying size and complexity.
• Preferred: Master’s degree in Fraud, Forensic Accounting, Business, or a related field.
• Preferred: Five years of experience in financial analysis within an acute care hospital or health insurance setting.
• Preferred: Five years of experience in professional billing, facility Patient Financial Services, Health Information Management (HIM), Internal Audit, reimbursement, or provider contracting.

Qualifications

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

Skills

Preferred certifications include Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Accredited Healthcare Fraud Investigator (AHFI), CPMA, CCA, or CCS.

Schedule

Full-time role with travel requirements of 0% to 25%. Position is primarily office-based but may require travel to various work sites.

Physical and Mental Demands

• Regularly teaches/trains others.
• Constantly lifts up to 10 pounds; occasionally lifts 10 to 25 pounds; rarely lifts 25 to 50 pounds.
• Physical work site required.