Healthcare Fraud Investigator (AHFI, CFE)
Location: Remote,
Job Type: Full-Time
Company: HireAligned
Salary: $60,000.00 - $92,000.00 per year
Category: Investigations
Job Description Apply Now
Integrity Advantage is actively seeking a qualified Healthcare Fraud Investigator (AHFI, CFE) to join our dedicated team in a remote capacity. This position offers a unique opportunity to contribute to the detection, investigation, and prevention of healthcare fraud, waste, and abuse (FWA). As a client-facing Healthcare Fraud Investigator, you will play a vital role in supporting health payers and entities by conducting thorough investigations and assisting in the recovery process. Integrity Advantage, a woman-owned business, is growing rapidly and looking for professionals who are committed to integrity, accountability, and excellence in service delivery. If you are an experienced investigator looking to be a pivotal part of a dynamic team, we encourage you to apply by clicking the job application button.
Healthcare Fraud Investigator (AHFI, CFE) - SummaryAs a Healthcare Fraud Investigator (AHFI, CFE), you will be responsible for managing the end-to-end process of healthcare fraud investigations. This includes gathering evidence, analyzing data, preparing detailed reports, and supporting clients through the entire investigative process. The role is remote, offering flexibility and the chance to work with multiple clients across various healthcare sectors such as Medicaid, Medicare, Federal Employee, and Commercial lines of business. You will be expected to uphold the highest standards of professionalism and confidentiality while providing exceptional customer service to clients.
Duties & Responsibilities- Conduct timely, comprehensive, and well-documented healthcare fraud investigations.
- Organize, prioritize, and manage investigative leads and cases across diverse levels of complexity.
- Collect and analyze evidence, research data, and other relevant information to substantiate or refute allegations of healthcare fraud, waste, or abuse.
- Utilize client fraud detection solutions to identify opportunities for investigation, including pre-payment and post-payment audits, and perform data mining using various analytical tools.
- Support multiple healthcare clients by addressing issues in Medicaid, Medicare, Federal Employee, and Commercial lines of business.
- Communicate investigation status updates and findings to clients in a clear and timely manner.
- Prepare detailed investigative reports, including results from medical record reviews and analytical findings.
- Apply knowledge of RAT-STATS for statistically valid random sampling in investigations.
- Provide support for law enforcement referrals, settlements, or legal proceedings as required by clients.
- Participate in and support additional company initiatives and projects as needed.
- Comprehensive 401(k) retirement plan.
- Dental, vision, and health insurance coverage.
- Paid time off to support work-life balance.
- Professional development assistance to support career growth.
- Bachelor's degree is required.
- Minimum of 2 years of healthcare claims investigation experience.
- Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) certification preferred; other relevant industry certifications will be considered.
- Strong knowledge of federal and state healthcare guidelines, including ICD, CPT, HCPCS, DRG, and revenue codes.
- Proficiency in Microsoft Word, Excel, and PowerPoint.
- Ability to travel for training, conferences, or onsite client support as needed (with appropriate notice).
- Familiarity with anti-fraud technology solutions, including ad-hoc queries, analytical tools, and case management applications.
- Demonstrated ability to work independently in a remote team environment with minimal supervision.
- Exhibits high integrity, accountability, and professionalism in all interactions.
- Possesses exceptional written and oral communication skills.
- Demonstrates strong analytical and problem-solving abilities.
- Adapts quickly to evolving technology and investigative tools.
- Delivers outstanding customer service in a client-facing environment.
- Thrives in a dynamic, growth-oriented company culture.
- Integrity Advantage is committed to fostering a diverse and inclusive workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.
- This is a remote position designed to offer flexibility and work-life balance.
- You will be an integral part of a team that is dedicated to making a meaningful impact in the fight against healthcare fraud, waste, and abuse.
- Join a collaborative environment where your expertise and insights are valued, and your professional growth is supported.
- Take the next step in your career by applying today through the job application button and contribute to the mission of Integrity Advantage in delivering trusted solutions for healthcare payers and organizations.