Fraud Investigator (31)

Summary

Conducting comprehensive fraud, waste, and abuse (FWA) investigations, the full-time SIU Investigator will analyze claims data, medical records, and provider information while collaborating with internal and external stakeholders to support case resolution and ensure compliance with regulations in a remote work environment.Key responsibilitiesConducts FWA investigations using various data sources to identify misconduct and support case resolutionPrepares investigative reports and collaborates with internal and external partners to coordinate investigative activitiesMonitors for emerging fraud schemes and recommends actions for further reviewRequired qualificationsBachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience2+ years of experience in fraud investigations, healthcare investigations, claims audits, or related fieldsExperience analyzing healthcare claims, medical records, and billing documentation preferredAccredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or similar certification preferred

Job Description

Conducting comprehensive fraud, waste, and abuse (FWA) investigations, the full-time SIU Investigator will analyze claims data, medical records, and provider information while collaborating with internal and external stakeholders to support case resolution and ensure compliance with regulations in a remote work environment.Key responsibilitiesConducts FWA investigations using various data sources to identify misconduct and support case resolutionPrepares investigative reports and collaborates with internal and external partners to coordinate investigative activitiesMonitors for emerging fraud schemes and recommends actions for further reviewRequired qualificationsBachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or a related field; or equivalent experience2+ years of experience in fraud investigations, healthcare investigations, claims audits, or related fieldsExperience analyzing healthcare claims, medical records, and billing documentation preferredAccredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or similar certification preferred