Position Details
About this role
Senior Investigator conducts complex investigations into healthcare fraud and abuse to recover funds and ensure compliance with regulations, including presenting referrals and coordinating with law enforcement.
Key Responsibilities
- Routinely handles complex cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment
- Investigates to prevent payment of fraudulent claims
- Researches and prepares cases for clinical and legal review
- Documents all appropriate case activity in case tracking system
- Facilitates referrals and presents findings to internal/external stakeholders
Technical Overview
Technical scope includes knowledge of medical coding (CPT/HCPCS/ICD), case documentation tools, and basic data analysis with Microsoft Office applications.
Ideal Candidate
The ideal candidate is a seasoned healthcare fraud investigator with 3+ years handling fraud, waste and abuse investigations; strong CPT/HCPCS/ICD coding knowledge; proficient with Word/Excel/Outlook and capable of presenting cases in legal settings.
Must-Have Skills
Nice-to-Have Skills
Tools & Platforms
Required Skills
Hard Skills
Soft Skills
Certifications
Preferred
Industry & Role
Keywords for Your Resume
Deal Breakers
Lack of 3+ years in healthcare fraud investigations, No CPT/HCPCS/ICD coding knowledge, Inability to travel or participate in legal proceedings
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