Lead Investigator – Validation, Fraud, Waste & Abuse

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

📋 Description

• Identify, investigate, analyze, and assess instances of potential fraud, waste, and abuse.

• Proactively monitor provider activities to uncover patterns, anomalies, and emerging trends that require further examination.

• Employ data analytics, claims review, and industry intelligence to identify potential fraud, waste, abuse, or non-compliance.

• Utilize claims data, dashboards, and predictive models to pinpoint providers with unusual billing patterns or signs of potential fraud, waste, and abuse.

• Analyze investigation data and present findings and recommendations through written summaries and/or presentations.

• Conduct training related to investigations.

• Support legal processes as necessary, which may include testifying in court or collaborating with law enforcement to prepare civil or criminal cases.

• Stay informed about relevant laws, regulations, and standards.

• Engage in special projects as needed.

• Fulfill responsibilities outlined in the annual Performance Plan.

• Complete special projects and other assigned tasks.

⛳️ Requirements

• Bachelor’s Degree in a related field or an equivalent combination of education, professional training, and work experience.

• Minimum of 2 years of relevant healthcare fraud, waste, and abuse investigative experience.

• Experience in proactive data mining.

• Familiarity with sampling and data extrapolation techniques.

• Advanced proficiency in Excel is required.

• Preferred certifications include Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Specialist (CFS), or Certified Fraud Examiner (CFE).

• Prior experience with RAT-STATS is preferred.

• Familiarity with Cotiviti FWA tools such as Sentinel, Commander, and/or Informant (Stars Solutions) is preferred.

• Excellent verbal and written communication skills.

• Strong listening and observational abilities.

• Keen attention to detail with a high degree of accuracy.

• Effective organizational and prioritization skills, along with the ability to manage multiple tasks.

• Must have a work location within the continental US.

• Must provide a high-speed internet connection and a distraction-free work environment.

• Must be able to establish a dedicated, secure workspace.

• Must ensure high-speed internet access/connectivity and maintain an office setup.

• Must be capable of performing duties with or without reasonable accommodation.

🏝️ Benefits

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Disability insurance.

• Life insurance coverage.

• 401(k) savings plans.

• Paid family leave.

• 9 paid holidays per year.

• 17-27 days of Paid Time Off (PTO) annually, depending on specific level and length of service.

• Remote work arrangement from home.

• Very limited travel required.

• High-speed internet and dedicated secure workspace requirements supported as part of the work setup provisions.