Investigator (Healthcare Fraud)

Location: Remote work from Pennsylvania, United States

Company

hirify.global operates in the health insurance and healthcare sector.

What you will do

• Investigate potential and existing provider, member, facility, pharmacy, group, and employee fraud, waste, and abuse.
• Conduct interviews, field investigations, case reviews, and special projects.
• Develop and maintain the annual anti-fraud program, including training, awareness activities, and regulatory fraud plans and reports.
• Coordinate internal and external data extracts, identify improper payments, and refer cases to committees, regulators, and law enforcement.
• Deliver audit results, negotiate overpayments, coordinate financial recoveries, and work with Finance on financial statement recording.
• Conduct proactive and investigative audits, including contract, commission, surveillance, workers' compensation, IME, and OFAC reviews.

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.
• At least three years of relevant progressive experience in health insurance and/or healthcare fraud investigations.
• 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, analytical, and problem-solving skills.

Nice to have

• Master's degree in Fraud, Forensic Accounting, Business, or a related field.
• Experience in financial analysis, patient financial services, HIM, internal audit, reimbursement, or provider contracting.
• Certifications such as CFE, CPC, COC, AHFI, CPMA, CCA, or CCS.

Culture & Benefits

• Remote work arrangement from Pennsylvania.
• Regular travel requirement of 0%–25% for investigations and work-site activities.
• Work includes collaboration with internal business units, Finance, committees, regulatory agencies, and law enforcement.
• Compliance with HIPAA, information security policies, the Code of Business Conduct, and applicable laws and regulations is required.