Fraud Investigator

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct entry-level investigations and audits related to fraud under the close guidance of a team manager and/or team lead.

• Assist in investigating medical service providers and prepare cases and reports for law enforcement referrals, educational purposes, overpayment recovery, and administrative actions.

• Collaborate with internal teams, external agencies, state and federal investigators, and other personnel.

• Manage multiple caseloads simultaneously while organizing and analyzing supporting data.

• Contribute to complex reports by applying relevant regulations or rules to the affected programs.

• Conduct research to grasp pertinent offenses and carry out effective investigations and audits.

• Identify or confirm suspected violations through observation, record examination, and interviews.

• Evaluate investigation/audit findings to determine if allegations are substantiated and recommend suitable corrective measures.

• Draft objective and precise correspondence, communicating with tact.

• Uphold the confidentiality of health privacy information and adhere to applicable laws, rules, and regulations.

• Adapt to unforeseen situations, modify plans, and implement effective strategies as necessary.

⛳️ Requirements

• 0 years of experience with a BS/BA degree, or 4 years of experience with a HS diploma/equivalent.

• Experience in investigative and analytical roles.

• Excellent communication and organizational abilities.

• Strong computer knowledge and skills.

• U.S. citizenship is required.

• A solid background in investigations or compliance audits is preferred for the most competitive candidates.

• Experience in reviewing claims for technical requirements, conducting medical reviews, and/or developing fraud cases and identifying overpayments is advantageous for the most competitive candidates.

• Familiarity with investigative or audit practices concerning healthcare providers is preferred for the most competitive candidates.

• Understanding of Medicare and/or Medicaid programs, rules, regulations, policies, and procedures is preferred for the most competitive candidates.

• Experience in evaluating, reviewing, and analyzing medical claims and records is preferred for the most competitive candidates.

• Ability to learn and utilize various data systems, equipment, and tools used in investigations.

• Capability to research and draw logical conclusions.

• Proficiency in documenting investigative/audit workloads and identifying regulatory violations or alleged fraud schemes.

• Competence in organizing case files and accurately documenting all actions taken.

• Ability to write correspondence, reports, and referral summary letters.

• Skill in interpreting laws and regulations.

• Capacity to handle confidential materials responsibly.

• Timeliness in reporting work activities.

• Ability to work collaboratively under direct supervision as a team member.

• Willingness to attend meetings and training sessions.

🏝️ Benefits

• Telework opportunities available for those in the Eastern Time Zone.

• Employees may qualify for overtime pay.

• Employees may be eligible for shift differentials.

• Employees may receive a discretionary bonus.

• Overnight travel may be necessary.