Description

You will identify and investigate suspected fraud, waste, and abuse in medical claims and enrollment data, managing cases from identification to resolution, including data mining, investigation planning, and reporting to regulatory agencies. You'll work independently to build evidentiary files and support recovery and legal actions.

Requirements

• 3+ years healthcare fraud investigation or law enforcement investigation experience
• 3+ years experience with fraud statutes, regulations, and federal anti-FWA guidelines
• Experience with HIPAA, data privacy, and data security processes preferred
• Bachelor's degree in Criminal Justice or related field preferred
• CFE, AHFI, CAFP, CPC or similar certification preferred

Responsibilities

• Identify and conduct investigations into suspected FWA with high autonomy
• Document findings with formal investigative reports, tables, graphs, and audit logs
• Meet metrics for caseload and turnaround times
• Monitor providers with substantiated findings for behavior change
• Build evidentiary files for recovery, legal action, or regulatory referrals