Fraud Investigator - Maine Licensed

Job Summary

To investigate suspected fraud, waste, and abuse (FWA) within health plans, the full-time remote SIU Investigator - Maine Licensed will manage a caseload from intake through resolution, including data analysis, medical record reviews, and coordination with law enforcement and oversight entities.

Key responsibilities

• Investigates FWA cases from initiation to resolution, developing plans that define allegations and financial exposure
• Analyzes claims data and reviews medical records against regulatory requirements and coding guidelines
• Conducts outreach and interviews with members and providers, maintaining thorough documentation and preparing referrals to oversight entities

Required qualifications

• Bachelor's degree in criminal justice, health care administration, accounting, or a related field, or equivalent experience
• Preferred certifications: AHFI, CFE, CPC, CCS, or CPMA
• Five or more years of experience in health care fraud investigation or related fields
• Knowledge of Medicare Advantage program integrity requirements and relevant laws
• Strong command of CMS-1500 and UB-04 claim formats and advanced skills in Excel, SQL, or PowerBI