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Investigator

120 5th Avenue Place, Pittsburgh PA 15222-3099, United States

Full time

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Job DescriptionWorking with UsBenefits & PerksHear From Our TeamHow We Hire

Job Details

Category Audit & Compliance

Type Full time

Location(s) 120 5th Avenue Place, Pittsburgh PA 15222-3099, United States

Brand Highmark Inc.

Posted 11/10/2026

Req ID J289814

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Job Description

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

This job 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. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. The incumbent is also responsible for the field investigative work necessary to complete a review of a special project, potential fraud, waste and abuse case, conducting the initial investigations and coordinating the recovery/savings of money related to fraud, waste and abuse. The incumbent 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. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.

ESSENTIAL RESPONSIBILITIES

• Performs investigations into potential and existing provider and member fraud, waste and abuse activities. Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, and/or employees of Highmark and Subsidiaries. Conduct Interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project. Determines the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, doctors' agreements, contract, etc.
• Develop and maintain annual anti-fraud program which includes facilitating fraud training and fraud awareness day, as well as filing annual fraud plans and reports according to state regulations. Responsible for updating annually the changes in insurance laws with regard to lines of business
• Coordinates data extracts by assessing multiple databases both internally and externally. Takes action to prevent further improper payments. Forwards case to the Credentialing and/or Medical Review Committee, law enforcement and regulatory agencies.
• Responsible for completing all necessary field (externally) investigative work for resolution or alleged fraud/waste and abuse cases or special projects.
• Provides advisory support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.
• Engages in delivery of audit results and overpayment negotiations. Responsible for recovery/ savings of misappropriated funds paid by Highmark and affiliated companies and work with Finance to ensure proper recording the financial statements.
• Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements. Audits consist of contract, commissions, surveillance, workers' compensation and IME. In addition, this position will complete Office of Foreign Asset Control (OFAC) to ensure payments are not issued to unauthorized parties.
• Other duties as assigned or requested.

EDUCATION

Required

• Bachelor"s Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field

Substitutions

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

Preferred

• Master"s Degree in Fraud, Forensics Accounting, Business or related field

EXPERIENCE

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
• 1 year in professional billing, facility Patient Financial Services, HIM, Internal Audit, Professional/Facility Reimbursement or Provider Contracting

LICENSES or CERTIFICATIONS

Required

• None

Preferred (any of the following)

• Certified Fraud Examiner (CFE)
• Certified Professional Coder (CPC)
• Certified Outpatient Coder (COC)
• Accredited Healthcare Fraud Investigator (AHFI)

SKILLS

• Must have knowledge of provider facility payment methodology, claims processing systems and coding and billing proficiency
• Must have understanding of technical and financial aspects of the health insurance industry
• Strong personal computer skills, along with the ability to use fraud/abuse data mining tools are required
• Must possess excellent communication skills and be detailed oriented
• Strong written and oral communication skills
• Strong relationship building skills
• Client focused with strong business acumen
• Self-starter with the ability to work under pressure independently and as part of a team
• Ability to think strategically and act proactively to create strong trust and confidence with business units
• Strong innovative problem-solving capabilities

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

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.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice

Why Choose Highmark Inc.?

As one of the nation"s leading health insurers, Highmark Inc. relies on a passionate team of over 5,000 people to make healthcare higher-quality, accessible, and affordable. We are known for how deeply we care-about our members and our employees. If you are looking to build a career with real purpose, you belong at Highmark.

Benefits & Perks

Taking Care of You

Your Benefits at a Glance

• Health: Complete medical, dental, vision, prescription, HSA, and FSA coverage.
• Time Off: Paid vacation, holidays, and dedicated volunteer time.
• Finance: Employer-sponsored 401(k), life/disability insurance, and tuition reimbursement.
• Perks: Exclusive team discounts on shopping, memberships, and events.

Medical Coverage

Medical, prescription drug, dental, and vision coverage

Paid Time Off

Vacation, holidays, volunteering

Retirement Package

Employer-sponsored 401(k) plan

Insurance & Coverage

Life, AD&D and disability insurance

Onsite & Preventative Care

We make staying healthy easy with 100% covered preventative exams (including flu shots) and onsite pharmacy services at major campuses. Plus, stay active with free fitness center access at major Highmark campuses, Allegheny General, and West Penn Hospital.

Make Mindful Changes

Secure bicycle parking at major campuses. Healthy food options at onsite cafeterias. Stress management classes including yoga, mindfulness, and meditation.

Holistic Support, 24/7

Work-life resources including assistance programs and financial counseling services. 24/7 telephone access to health and wellness coaching.

Get Rewarded for Giving Back

Health incentive program that rewards team members. Team member networks to gather in the name of health. Paid volunteer time and incentives for making a difference.

Hear from Our Team

Real people, real stories

"I have met some really great people over the years at Highmark Health and the company has treated me really well. I get really good benefits. I"ve always been rewarded for working hard. That"s what keeps me here."

Victoria T.

Associate Strategy Analyst, enGen

"I love participating with the PRIDE BRG. It"s an engaged, dynamic group of almost 400 people. I also love to turn on the digital hub on my computer and see what"s going on with any of the Business Resource Groups. It"s really neat to be able to support other BRGs and see others support PRIDE. Every time I go to a different BRG event, I always feel welcome, even if I"m not part of that group."

Amanda M.

Director of Social Determinants of Health | Vice Chair of PRIDE

Our Hiring Process: Step-by-Step

1. Apply

Find a role that sparks your passion and submit your application! We'll send an immediate confirmation email, and our team will review your qualifications over the next 1-2 weeks.

2. Interview

If your profile is a great match, we'll reach out to schedule your interview-whether by phone, video, or in person. Don"t worry, we'll provide all the prep details in advance so you can shine.

3. Job Offer

The moment you've been waiting for! If selected, we'll connect to celebrate and walk you through the details: compensation, benefits, paid time off, and all the perks of joining the team.

4. Pre-Employment

After you accept online, we'll guide you through standard screening (including a background check and drug screen, plus health screenings for certain clinical roles). Once cleared, we"ll officially confirm your start date!

5. Onboarding

Welcome aboard! Before Day 1, we'll send everything you need to hit the ground running-including your schedule, location, and the required identification documents to bring with you.

Bonus Fast-Track Tip

Applying for EVS, Dietary, or Customer Service roles? You can skip the traditional line and chat with Bridget, our AI recruiting assistant, to find open roles and schedule an eligible interview instantly.

Apply Now

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Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.

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 their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below. For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

Highmark Health. All Rights Reserved.