Healthcare Fraud Investigator in United States at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Healthcare Fraud Investigator based in the United States.

In this role, you will help protect the integrity of the healthcare system by investigating suspected fraud, irregularities, and potentially improper healthcare claims. You will combine investigative expertise, analytical thinking, and claims auditing skills to uncover suspicious activity, assess evidence, and recommend appropriate corrective actions. Working within a Special Investigations Unit, you will collaborate with internal stakeholders, healthcare providers, insurers, and law enforcement agencies to support thorough and effective investigations. Your responsibilities will include reviewing complex claims data, conducting interviews, preparing evidence packages, and documenting findings that may support recovery efforts or legal proceedings. This fully remote opportunity offers the chance to apply your investigative skills to meaningful work that promotes accountability, protects healthcare resources, and supports responsible claims management. You will contribute to a collaborative, results-oriented environment where accuracy, sound judgment, and clear communication are essential.

• 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.

• 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.

• 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.