Senior Fraud Investigator - VA Licensed

Job Summary

To support a growing healthcare organization, the full-time Senior Fraud Investigator - VA Licensed will conduct in-depth investigations of suspected fraud and abuse, perform audits, and ensure compliance with health insurance policies, all while working remotely with occasional travel to Virginia Beach.

Key responsibilities

• Conduct investigations related to fraud or abuse across various interactions involving providers, pharmacies, and members
• Perform routine and on-site audits of coding practices and reimbursement systems
• Prepare departmental reports and assist in training staff on updated policies and procedures

Required qualifications

• Bachelor's Degree in a related field is required
• Certified Professional Coder (CPC) is required (or must be obtained within 12 months of hire)
• Minimum of 5-8 years of investigative experience or 3-5 years in healthcare investigations
• Experience with fraud, waste, and abuse analysis, including data mining and pre-pay investigations
• Preferred certifications include Certified Forensic Interviewer (CFI), Certified Fraud Specialist (CFS), and Certified Fraud Examiner (CFE)