Healthcare Fraud Investigator

Accountabilities:

Conduct fraud investigations and audits: Investigate suspected healthcare fraud and potentially fraudulent claims involving providers and other parties, ensuring that cases are assessed thoroughly and objectively.
Analyze claims and investigative evidence: Review healthcare claims, audit results, investigative findings, and supporting documentation to identify suspicious patterns, inconsistencies, discrepancies, and indicators of potential fraud.
Document findings and recommend actions: Prepare accurate, clear, and comprehensive investigative reports, summaries, and recommendations to support appropriate case resolution and corrective measures.
Develop evidence packages: Assemble and organize supporting documentation for referrals to external stakeholders, including contract holders, state insurance fraud bureaus, and law enforcement agencies.
Conduct fieldwork and interviews: Lead on-site inspections and interview patients, healthcare providers, and other relevant parties when necessary to establish facts and gather additional evidence.
Respond to legal and regulatory requests: Address subpoenas and requests for information from law enforcement agencies and state Departments of Insurance, ensuring that responses are complete and appropriately documented.
Support legal proceedings: Represent the organization as a witness in judicial proceedings when required, providing factual information and supporting the presentation of investigative findings.
Contribute to special investigations projects: Apply expertise in fraud detection, healthcare investigations, claims auditing, and related Special Investigations Unit activities to support broader departmental initiatives.
Maintain investigation tracking and reporting: Prepare and maintain accurate case records, reports, and documentation to support effective monitoring, compliance, and reporting of investigative activities.
Requirements:
Relevant professional experience: At least three years of experience in health insurance investigations, auditing, or a closely related field.
Investigative and analytical expertise: Strong ability to evaluate complex information, identify inconsistencies and suspicious activity, assess evidence, and draw well-supported conclusions.
Healthcare claims knowledge: Familiarity with healthcare claims, provider investigations, fraud detection methods, auditing practices, or Special Investigations Unit operations is highly desirable.
Written and verbal communication: Excellent communication skills, including the ability to prepare detailed investigative reports, explain findings clearly, conduct professional interviews, and communicate effectively with internal and external stakeholders.
Technical proficiency: Working knowledge of Microsoft Excel, Access, and Word for analyzing information, organizing case documentation, and preparing reports.
Education: A bachelor's degree in criminal justice or a related discipline is preferred.
Professional certifications: An Accredited Health Care Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) credential is an advantage.
Attention to detail and sound judgment: Ability to handle sensitive information responsibly, maintain accurate records, exercise discretion, and make objective, evidence-based recommendations.
Remote work requirements: Candidates working remotely must have a cable broadband or fiber-optic internet connection with minimum speeds of 10 Mbps download and 5 Mbps upload.
Benefits:
Competitive annual salary: Expected base salary between $68,300 and $113,900, depending on relevant experience, qualifications, geographic location, and other applicable factors.
Annual bonus opportunity: Eligibility to participate in an annual bonus plan.
Remote flexibility: Fully remote work arrangement for eligible candidates based in the United States.
Comprehensive healthcare coverage: Medical, dental, and vision insurance, along with well-being and behavioral health programs, beginning on the first day of employment.
Retirement savings: Access to a 401(k) retirement savings plan.
Life insurance: Company-paid life insurance coverage.
Paid time off: At least 18 days of paid time off annually, in addition to paid holidays.
Leave programs: Access to leaves of absence in accordance with applicable policies.
Professional development: Tuition reimbursement to support continued learning and career advancement.
Meaningful work: An opportunity to help detect and prevent healthcare fraud, strengthen claims integrity, and protect valuable healthcare resources.