Healthcare Fraud Investigator

Job Summary

Conducting detailed investigations into potential fraud, waste, and abuse in healthcare claims, the full-time remote Special Investigator will review medical records and claims data, collaborate with internal teams, and prepare comprehensive reports for compliance and recovery actions.

Key responsibilities

• Review medical records and claims data to verify charges and assess medical necessity
• Collaborate with internal auditors and legal support teams to build cases and document findings
• Prepare clear investigative reports and communicate results and recommendations to stakeholders

Required qualifications

• Bachelor's degree in healthcare administration, health information management, criminal justice, auditing, or a related field
• Strong investigative and analytical skills with experience in reviewing claims and identifying fraud patterns
• Knowledge of healthcare coding, billing, and documentation standards
• Experience with data analytics tools and large data sets in a healthcare or payer environment
• Understanding of HIPAA and compliance practices related to protected health information