Senior Investigator (Healthcare Fraud)

Location: Remote work from Pennsylvania, United States; travel to work sites may be required for field investigations.

Company

hirify.global provides health insurance and related healthcare services.

What you will do

• Investigate provider, member, facility, pharmacy, group, and employee fraud, waste, and abuse allegations.
• Conduct interviews, field investigations, audits, data reviews, and special projects.
• Coordinate data extracts, identify improper payments, and support referrals to law enforcement, regulators, and internal committees.
• Develop and maintain anti-fraud programs, deliver training, and prepare annual fraud plans and reports.
• Negotiate overpayment recoveries, coordinate savings with Finance, and support accurate financial reporting.
• Serve as a subject matter expert, mentor investigators, and lead projects of varying size and complexity.

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.
• Five years of 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 communication, relationship-building, analytical, problem-solving, and computer skills, including the use of fraud and abuse data-mining tools.
• Work from home in Pennsylvania, United States; travel requirement is 0%–25%.

Nice to have

• Master’s degree in Fraud, Forensic Accounting, Business, or a related field.
• Certified Fraud Examiner, Certified Professional Coder, Certified Outpatient Coder, or Accredited Healthcare Fraud Investigator certification.
• Experience in financial analysis, professional billing, patient financial services, health information management, internal audit, reimbursement, or provider contracting.

Culture & Benefits

• Office-based position performed remotely from Pennsylvania.
• Work includes collaboration with internal business units, Finance, regulatory bodies, law enforcement, and medical review committees.
• Responsibilities require compliance with HIPAA, information-security policies, federal and state regulations, and the company’s code of business conduct.
• Physical work site required; lifting requirements are generally up to 10 pounds.