Investigator (Healthcare Fraud)

TL;DR

Investigator (Healthcare Fraud): Investigating provider and member fraud, waste, and abuse cases for a health insurance organization with an accent on field investigations, audits, case development, and financial recovery. Focus on analyzing claims and payment data, coordinating with regulatory and law enforcement agencies, and building cases that support recoveries and legal action.

Location: Remote from Pennsylvania, United States; the position is designated as working at home and requires occasional travel of 0%–25%.

Company

hirify.global is a healthcare organization providing health insurance and related services.

What you will do

• Investigate suspected and existing fraud, waste, and abuse involving providers, members, facilities, pharmacies, groups, and employees.
• Conduct interviews, gather records and claims information, define investigation scope, and complete external field investigations.
• Develop and maintain the annual anti-fraud program, including training, awareness activities, and regulatory fraud plans and reports.
• Coordinate data extracts and use internal and external databases to identify improper payments and prevent further losses.
• Prepare cases for credentialing committees, regulators, and law enforcement agencies, and provide advisory support through case closure.
• Conduct compliance audits, negotiate overpayments, coordinate recoveries with Finance, and complete OFAC payment 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.
• Three years of relevant progressive experience in health insurance or healthcare fraud investigations.
• Knowledge of provider and facility payment methodologies, claims processing systems, coding, billing, and the financial and technical aspects of health insurance.
• Experience using fraud and abuse data-mining tools, strong written and verbal communication, attention to detail, and relationship-building skills.
• Ability to work independently under pressure, collaborate with teams, think strategically, and solve problems proactively.
• Must be based in Pennsylvania, United States.

Nice to have

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

Culture & Benefits

• Work-from-home position with occasional travel to work sites.
• Regular interaction with internal business units, Finance, credentialing and medical review committees, regulators, and law enforcement agencies.
• Work governed by healthcare privacy, information security, ethical conduct, and regulatory compliance requirements.
• Access to confidential customer and health information requires compliance with HIPAA and company privacy policies.