Lead Investigator (Healthcare Fraud)

Location: Working from home in Pennsylvania, United States

Company

hirify.global operates in health insurance and healthcare services.

What you will do

• Monitor and coordinate investigative activities, serving as the initial point of contact for internal and external stakeholders.
• Lead and mentor investigators, provide subject-matter guidance, and support departmental special projects.
• Investigate suspected provider and member fraud, waste, and abuse through interviews, records review, data analysis, and field investigations.
• Develop and maintain the annual anti-fraud program, deliver fraud training, and file fraud plans and reports required by state regulations.
• Conduct audits, including contract, commission, surveillance, workers’ compensation, IME, and OFAC payment reviews.
• Coordinate recoveries, overpayment negotiations, case referrals, and collaboration with Finance, law enforcement, regulators, and medical review committees.

Requirements

• Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field, or six years of related progressive experience in lieu of a degree.
• Seven years of experience in health insurance and/or healthcare fraud investigations.
• Three years of experience leading projects of varying size and complexity.
• Knowledge of provider and facility payment methodologies, claims processing systems, coding, billing, and the technical and financial aspects of health insurance.
• Experience using fraud and abuse data-mining tools, with strong written, oral, analytical, communication, and relationship-building skills.
• Travel requirement: 0%–25%; the position requires a physical work site and may involve travel to investigation sites.

Nice to have

• Master’s degree in Fraud, Forensic Accounting, Business, or a related field.
• Five years of financial analysis experience in an acute-care hospital or health insurance setting.
• Five years of experience in professional billing, patient financial services, HIM, internal audit, reimbursement, or provider contracting.
• Certifications such as CFE, CPC, COC, AHFI, CPMA, CCA, or CCS.

Culture & Benefits

• Work is performed primarily from a home office in Pennsylvania.
• The role includes training and mentoring responsibilities and collaboration with internal and external partners.
• Employees must follow HIPAA, information security, privacy, legal, and business conduct requirements.
• Physical demands include frequent lifting of up to 10 pounds and occasional lifting of 10–25 pounds.