Lead Investigator (Healthcare Fraud)

Location: Remote work from Pennsylvania, United States; physical work site required

Company

hirify.global provides health insurance and related healthcare services.

What you will do

• Monitor and coordinate investigative activities, serving as the primary contact for internal and external investigation participants.
• Lead and mentor investigators, provide subject-matter guidance, and manage special projects.
• Investigate provider and member fraud, waste, and abuse through interviews, document reviews, data analysis, and field investigations.
• Develop and maintain the annual anti-fraud program, including training, fraud awareness activities, and regulatory filings.
• Coordinate audits, overpayment negotiations, fund recovery, payment prevention, and accurate financial recording.
• Prepare and refer cases to law enforcement, regulatory agencies, Credentialing, 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 health insurance industry or healthcare fraud investigation experience.
• Three years of experience leading projects of varying size and complexity.
• Knowledge of provider and facility payment methodology, claims processing systems, coding, billing, and health insurance operations.
• Experience using fraud and abuse data-mining tools, strong analytical and communication skills, and the ability to work independently and collaboratively.
• Travel requirement: 0–25%; the position is office-based and requires a physical work site.

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.
• 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-from-home arrangement based in Pennsylvania.
• Regular collaboration with law enforcement, regulatory agencies, finance, credentialing, and medical review functions.
• Work involving confidential customer information requires compliance with HIPAA, privacy policies, information security standards, and the Code of Business Conduct.