Investigator (Healthcare Fraud)

Location: Working from home in Pennsylvania, United States

Company

hirify.global provides health insurance and related healthcare services through hirify.global and its subsidiaries.

What you will do

• Investigate suspected and existing provider, member, facility, pharmacy, group, and employee fraud, waste, and abuse.
• Conduct interviews, review complaints and inquiries, gather claims, licensing, contractual, and policy information, and complete field investigations.
• Develop and maintain the annual anti-fraud program, deliver fraud training, and file fraud plans and reports required by state regulations.
• Coordinate data extracts across internal and external databases and take action to prevent improper payments.
• Refer cases to credentialing and medical review committees, law enforcement, and regulatory agencies, providing advisory support through case closure.
• Conduct compliance audits, negotiate overpayments, coordinate recovery and savings, and work with Finance on financial recording.

Requirements

• Bachelor’s degree in Accounting, Finance, Business Administration, Nursing, IT, or a related field; six years of related progressive experience may substitute for the degree.
• Knowledge of provider and facility payment methodology, claims processing systems, coding, and billing.
• Understanding of the technical and financial aspects of the health insurance industry.
• Strong computer skills and experience using fraud and abuse data-mining tools.
• Excellent written and oral communication, relationship-building, problem-solving, and organizational skills.
• Ability to work independently under pressure and collaborate with business units, committees, regulators, and law enforcement.

Nice to have

• Three years of relevant experience in health insurance or healthcare fraud investigations.
• Experience in financial analysis, professional billing, patient financial services, health information management, internal audit, reimbursement, or provider contracting.
• Master’s degree in Fraud, Forensic Accounting, Business, or a related field.
• Certifications such as CFE, CPC, COC, AHFI, CPMA, CCA, or CCS.

Culture & Benefits

• Work-from-home position based in Pennsylvania.
• Regular travel requirement of 0%–25%, including travel to external work sites when needed.
• Work includes protecting confidential customer, cardholder, and health information under HIPAA and company security policies.
• Compliance with applicable federal and state laws, regulations, and the company’s code of business conduct is required.