Senior Investigator – Pre-Pay, Healthcare FWA

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

📋 Description

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

• Actively monitor provider activities for patterns, anomalies, and emerging trends that require further investigation.

• Utilize data analytics, claims reviews, and industry intelligence to uncover fraud, waste, abuse, or instances of non-compliance.

• Employ claims data, dashboards, and predictive models to pinpoint unusual billing patterns among providers.

• Analyze information gathered during investigations and present findings and recommendations in written reports and/or presentations.

• Conduct training related to investigations.

• Assist in legal proceedings, including providing court testimony and collaborating with law enforcement to prepare civil or criminal cases.

• Stay updated on relevant laws, regulations, and standards.

• Fulfill annual responsibilities as outlined in the Performance Plan.

• Complete special projects and additional assigned tasks.

• Collaborate with the pre-pay Fraud, Waste & Abuse team.

⛳️ Requirements

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

• 5-8 years of pertinent investigative experience in healthcare FWA.

• Experience in proactive data mining techniques.

• Advanced Excel skills are required.

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

• Exceptional verbal and written communication abilities.

• Strong listening and observational skills.

• A keen attention to detail and a high degree of accuracy.

• Effective organizational and prioritization skills, along 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).

• Must be capable of sitting and using a computer keyboard for extended periods.

• Willingness to travel up to 15% as needed.

• Flexibility and readiness to engage in international organizational processes and global-time-zone conference calls.

• Availability for after-hours and/or weekend work when necessary to meet major deliverables and deadlines.

• Must ensure a dedicated and secure workspace.

• Must have high-speed internet access/connectivity, and be responsible for office setup and maintenance.

• Capable of performing duties with or without reasonable accommodations.

🏝️ Benefits

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Disability insurance coverage.

• 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, based on specific level and length of service.

• Work-at-home position.

• High-speed internet is required; all other equipment will be provided.