Senior Investigator – Lead Validation, Healthcare FWA

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 may require further investigation.

• 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 displaying unusual billing patterns or potential fraud, waste, and abuse.

• Analyze information gathered during investigations and present findings and recommendations through written summaries and/or presentations.

• Conduct training related to investigations.

• Provide support for legal proceedings as necessary, including testifying in court or collaborating with law enforcement to prepare cases for civil or criminal actions.

• Maintain up-to-date knowledge of relevant laws, regulations, and standards.

• Participate in special projects as required.

• Fulfill all responsibilities as detailed in the annual Performance Plan.

• Complete all special projects and additional duties as assigned.

⛳️ Requirements

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

• 5-8 years of relevant fraud, waste, and abuse investigative experience.

• Experience in proactive data mining.

• Familiarity with sampling and data extrapolation; prior experience with RAT-STATS is preferred.

• Advanced proficiency in Excel is required.

• Experience with Cotiviti FWA tools (preferred) - Sentinel, Commander, and/or Informant (Stars Solutions).

• Strong verbal and written communication skills.

• Excellent listening and observation abilities.

• High attention to detail and accuracy.

• Effective organizational and prioritization skills with the ability to multitask.

• Preferred certifications include: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Specialist (CFS), Certified Fraud Examiner (CFE), Certified Forensic Interviewer (CFI), or Certified in Healthcare Compliance (CHC).

🏝️ Benefits

• Medical, dental, vision, disability, and life insurance coverage.

• 401(k) savings plans.

• Paid family leave.

• 9 paid holidays per year.

• 17-27 days of Paid Time Off (PTO) per year.