Healthcare Fraud Investigator

Position Summary - We are seeking highly skilled Special Investigative Unit (SIU) Investigators to support the Compliance & Legal Affairs Department. The SIU Investigator will lead investigations related to reports of non-compliance, fraud, waste, and abuse within the organization and across healthcare operations. The role requires strong analytical capabilities, independent judgment, meticulous attention to detail, and the ability to manage sensitive and complex cases, often involving regulatory or law enforcement agencies. Principal Duties & Responsibilities - Investigative Responsibilities - • Independently analyze public and internal HAP data to develop preliminary assessments and determine need for full investigations. • Develop investigative strategies and execute end-to-end investigations, including high-profile and complex healthcare fraud cases. • Collect, assemble, and document evidence required for proper adjudication. • Conduct on-site audits of provider records, focusing on billing appropriateness and compliance. • Conduct interviews with providers, employees, members, and witnesses. • Prepare detailed investigative and audit reports, summarizing trends, metrics, and findings for stakeholders and enforcement agencies. • Create well-structured fraud referrals for regulators, detailing alleged fraudulent activities. • Coordinate and collaborate with law enforcement and regulatory authorities. Compliance & Program Support - • Ensure adherence to OIG-effective compliance program elements by addressing issues promptly. • Manage an independent caseload, including tracking, trending, and reporting non-compliance. • Recommend and initiate investigative procedures for alleged violations of policies, regulations, or Code of Conduct. • Support operation of the compliance program by ensuring processes prevent illegal, unethical, or improper conduct. • Proactively develop new cases using data mining tools and findings. • Respond to complaints, document statements, and identify instances of fraud, waste, or abuse. • Identify patterns, trends, and schemes to generate new investigative leads. • Develop and deliver compliance-related training (FWA, HFH Non-retaliation policy, Code of Conduct, etc.). Teamwork & Collaboration - • Work effectively as part of the SIU team, contributing to collective goals. • Demonstrate adaptability and willingness to support various investigative tasks as needed. Required Skills & Competencies - • Experience using RAT-STATS or similar tools for sampling and extrapolation. • Strong proficiency in Excel: data analysis, macros, pivot tables, Power Query, automation, and visualization. • Experience with Microsoft Power BI and working SQL knowledge preferred. • Excellent verbal, written, and presentation skills. • Strong analytical, investigative, and auditing skills with an inquisitive mindset. • Knowledge of healthcare industry product lines (Medicare, Medicaid, ACA, commercial). • Strong understanding of healthcare payment methodologies. • Experience with FACETs or similar claims systems. • Strong interpersonal, organization, and communication skills. • Ability to work effectively with diverse groups at all levels. • High level of personal and professional ethics. • Must meet client customer service standards in communication, sensitivity, teamwork, and understanding. Required - Education & Experience Requirements - • Bachelor’s Degree • Minimum 3 years of experience in healthcare, pharmacy technician roles, claims adjudication, medical billing/coding, nursing, or law enforcement • Minimum 2 years conducting comprehensive investigations, preferably with law enforcement collaboration • Previous experience working for a health insurance payer • Previous experience using FACETs system • CFE (Certified Fraud Examiner) or AHFI (Accredited Healthcare Fraud Investigator) certification