Senior Investigator - Pre-Pay (Healthcare FWA)

Senior Investigator role focused on investigating healthcare fraud, waste, and abuse through data analysis, primarily using Excel. Not a physical investigation role, aligned with the pre-pay Fraud Waste & Abuse team.

Location: Remote (US)

Salary: $70,000–$90,000/yr

Responsibilities

• Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse.
• Proactively monitor provider activity to identify patterns, anomalies, and emerging trends.
• Utilize data analytics, claims review, and industry intelligence to detect potential fraud, waste, abuse, or non-compliance.
• Leverage claims data, dashboards, and predictive models to identify providers exhibiting atypical billing patterns or potential fraud, waste, and abuse.
• Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation.
• Conduct investigation-related training.
• Support legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
• Maintain current knowledge of relevant laws, regulations and standards.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.

Requirements

• Bachelor’s Degree in related discipline, or the equivalent combination of education, professional training and work experience.
• 5-8 years of related healthcare FWA investigative experience.
• Experience in proactive data mining.
• Advanced level skills in Excel required.
• Experience using Cotiviti FWA tools (preferred) - Sentinel, Commander, and/or Informant (Stars Solutions).
• Excellent verbal and written communication skills.
• Strong listening and observation skills.
• Attention to detail and high level of accuracy.
• Effective organizational and prioritization skills with multi-tasking ability.
• Preferred certifications: 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.

Additional Information

• This is a work-at-home position with access to high-speed internet required.
• Must be able to sit and use a computer keyboard for extended periods.
• Travel up to 15%.
• Flexibility to participate in global conference calls and after-hours/weekend work as needed.
• Must provide a dedicated, secure work area and high-speed internet connectivity.