Special Investigation Unit Investigator (Healthcare Fraud)

Location: Remote-NY

Salary: $56,200–$101,000 per year

Company

hirify.global provides healthcare services focused on connecting people with the care they need and improving access to effective care.

What you will do

• Conduct fraud, waste, and abuse investigations using referrals, claims data, medical records, interviews, data analytics, and other investigative resources.
• Review claims, provider billing practices, enrollment information, financial records, and supporting documentation to identify fraud, overpayments, abuse, and compliance concerns.
• Document investigative activities, findings, recommendations, outcomes, and case progression according to regulatory and organizational requirements.
• Prepare investigative reports, case summaries, referrals, and supporting materials for internal stakeholders, regulators, law enforcement, and other authorized parties.
• Collaborate with compliance, legal, provider and payment integrity teams, business partners, and external agencies on corrective actions, recoveries, audits, and case resolution.
• Support onsite audits, provider and member interviews, drive-by activities, regulatory responses, special projects, and monitoring of emerging fraud schemes.

Requirements

• Bachelor's degree in business, criminal justice, healthcare administration, public health, or a related field, or equivalent experience.
• At least five years of healthcare experience involving fraud, waste, and abuse investigations and audits, or five years of insurance claims or law-enforcement investigation experience.
• Alternatively, seven years of professional investigation experience involving economic or insurance-related matters.
• Experience analyzing healthcare claims, medical records, billing and coding documentation, provider data, financial information, or related investigative records is preferred.
• Ability to comply with applicable federal and state regulations, contractual requirements, privacy standards, investigative protocols, and organizational policies.

Nice to have

• Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or another related investigative, auditing, or compliance certification.

Culture & Benefits

• Health insurance, 401(k), stock purchase plans, tuition reimbursement, paid time off, and holidays.
• Flexible work approaches may include remote, hybrid, field, or office schedules.
• Equal opportunity workplace committed to diversity and inclusion.