Healthcare Fraud Investigator - Case Development
About the position Join a specialized Special Investigations (SIU) referral and case enhancement team focused on identifying and mitigating healthcare fraud. In this role, you’ll use your investigative experience and data‑driven insights to assess suspected fraud referrals, uncover high‑risk billing patterns, and guide meaningful investigations that protect patients and reduce financial risk for clients and customers.
Responsibilities
- Independently research, analyze, and assess suspected healthcare fraud referrals using investigative techniques and data analysis.
- Identify high‑risk billing behaviors, fraud trends, and potential overpayments through detailed data review.
- Evaluate referrals submitted to SIU and determine whether allegations warrant full investigation.
- Deliver clear, well‑structured case assessments with actionable investigative recommendations.
- Partner closely with investigators and field staff to develop leads and refine investigative strategies.
- Use technology and analytics to support complex investigations and adapt investigative direction as new information emerges.
- Monitor industry alerts, regulatory updates, and fraud bulletins to assess potential exposure.
- Handle sensitive and confidential information with integrity and professionalism.
Requirements
- 3 + years of experience in healthcare insurance investigation, audit or relevant experience
- Strong analytical, research, and problem‑solving skills
- Clear and concise written and verbal communication skills
- Proficiency with Microsoft Excel and Word
- If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
Nice-to-haves
- Bachelor’s degree in Criminal Justice or related field
- AHFI and/or CFE certification
- CPT and ICD‑10 coding knowledge
- Experience working with data analytics tools and investigative databases
Benefits
- Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs.
- We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays.