Fraud Investigation Specialist (31)

Summary

Conducting thorough fraud, waste, and abuse (FWA) investigations, the full-time Special Investigation Unit Investigator will review claims data, medical records, and provider information while collaborating with stakeholders to ensure compliance and support case resolution in a remote setting.Key responsibilitiesConducts FWA investigations using various data sources to identify potential misconductPrepares investigative reports and collaborates with internal and external partners to support case resolutionMonitors emerging fraud schemes and recommends actions for further reviewRequired qualificationsBachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or related field, or equivalent experienceMinimum of five years in the healthcare field focusing on fraud investigations or insurance claimsExperience analyzing healthcare claims, medical records, and related documentationPreferred certifications include Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)Experience with audits and compliance standards in healthcare settings is preferred

Job Description

Conducting thorough fraud, waste, and abuse (FWA) investigations, the full-time Special Investigation Unit Investigator will review claims data, medical records, and provider information while collaborating with stakeholders to ensure compliance and support case resolution in a remote setting.Key responsibilitiesConducts FWA investigations using various data sources to identify potential misconductPrepares investigative reports and collaborates with internal and external partners to support case resolutionMonitors emerging fraud schemes and recommends actions for further reviewRequired qualificationsBachelor's Degree in Business, Criminal Justice, Healthcare Administration, Public Health, or related field, or equivalent experienceMinimum of five years in the healthcare field focusing on fraud investigations or insurance claimsExperience analyzing healthcare claims, medical records, and related documentationPreferred certifications include Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)Experience with audits and compliance standards in healthcare settings is preferred