Senior Investigator, Special Investigations (Healthcare)

TL;DR

Senior Investigator, Special Investigations (Healthcare): Planning and executing complex investigations into healthcare fraud, waste, and abuse to protect members and the Medicare Fund with an accent on data mining and regulatory compliance. Focus on detecting aberrancies in claims, conducting internal employee investigations, and coordinating with federal and state law enforcement agencies.

Location: Remote (USA)

Salary: $75,000 - $110,000 / year

Company

hirify.global is an all-in-one healthcare company combining compassion, insurance, clinical care, and technology to improve the health and well-being of older Americans.

What you will do

• Perform data mining and analysis to detect outliers in claims, medical records, and healthcare transactions.
• Handle complex fraud, waste, and abuse (FWA) investigations and serve as a subject matter expert for SIU staff.
• Develop policies, procedures, and annual risk assessments related to FWA detection.
• Refer investigative findings to federal and state regulators and law enforcement agencies.
• Create and present trend reports and recommendations to senior leadership.
• Collaborate with internal stakeholders to facilitate fund recovery and corrective actions.

Requirements

• Bachelor’s Degree in Business, Criminal Justice, Healthcare, or equivalent experience.
• Minimum 3 years of experience in health insurance fraud investigation.
• Experience with Medicare and/or Medicaid programs (billing, reimbursement, audit).
• Proven experience conducting internal employee and contracted sales agent investigations.
• Knowledge of data analysis techniques and AI concepts for business processes.
• Must be based in the USA

Nice to have

• Certified Fraud Examiner (CFE) certification.
• Certified Professional Coder (CPC) certification.
• Strong analytical and report-writing skills.

Culture & Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.
• Generous paid time off and parental leave program.
• $100 monthly mobile or internet stipend.
• Stock options and bonus eligibility.
• 401K program.