Fraud Investigator II

Explore the Possibilitiesand Advance with Us. You can view all open jobs by clicking here or use the following search form to find jobs that suit your specificcareer interests. Category Business Unit Location Type Within Keyword When you join the UMass Chan Medical School team, you join us in advancing together to improve the health and well-being of our diverse communities throughout Massachusetts and across the US and the world. Together, we lead in education, research, health care delivery, and public service. Your life’s work is more than a career. It’s an expression of your passion, intellect, skill, and drive.UMass Chan's commitment to excellence, innovation, competitive benefits, and work-life integration will allow you to build a professionally rewarding career as we work together to better or improve the health of people around the globe. Fraud Investigator II Job Number : 2025-48460 Category: Administrative Professional Location : Westborough, MA Shift: Day Exempt/Non-Exempt: Exempt Business Unit: ForHealth Consulting Department: ForHealth Consulting - Health Care Finance Solutions - Financial Compliance - W407618 Job Type: Full-Time Num. Openings : 1 Post Date : Oct. 24, 2025 Work Location: Hybrid Salary Minimum : USD $78,000.00/Yr. Salary Maximum : USD $88,000.00/Yr. At ForHealth Consulting we partner with purposeful organizations to make the healthcare experience better: more equitable, effective, and accessible. We aim to transform the health care experience to one that addresses the needs and concerns of the individual and is inclusive of all. If you are interested in using your data analysis skills and your passion for reducing fraud, waste, and abuse in a healthcare program this is an excellent opportunity for you. Are you looking for a hybrid schedule, state benefits, and meaningful work? Come join our team. ** Hybrid requirement ** - Once a month on site. GENERAL SUMMARY OF POSITION: Under the general direction of the Associate Director, or designee, the Fraud Investigator II serves a crucial role in combating fraud, waste and abuse (“FWA”) within the Medicaid program. Investigations involve extensive research to identify industry trends and patterns which target aberrant billing practices. The Investigator II collaborates with the Associate Director on more complex case reviews as needed, in addition to performing activities related to data mining, data analysis and recoveries. With increasing independence, the Investigator II is assigned to multiple provider types and serves as a senior investigator in the Unit., The Investigator II will coach other investigators on developing techniques to find provider schemes based on federal and state regulations that govern Medicaid. MAJOR RESPONSIBILITIES: Consistently apply in-depth knowledge of federal and state regulations and healthcare industry standards. Conduct independent data mining and data analysis techniques utilizing claims data to detect aberrancies and outliers in claims and develop trends and patterns for potential cases. Develop algorithms, queries, and reports to detect potential FWA activity. Analyze member records and claims data to ensure compliance with applicable regulations, contracts and policy manuals. Develop reports of investigative findings, compile case file documentation, calculate overpayments, and issue findings in accordance with agency policies and procedures. Document work performed and audit results based on pre-determine standards and guidelines. Communicate with providers routinely regarding issues including audit findings, recoveries and educational feedback. Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance, based on findings. Determine compliance with applicable Medicaid regulations by examining records Assist investigator I staff with recognizing and identifying fraudulent patterns for increasingly complex cases. Serve as a resource for departments to research and resolve integrity inquiries. Update appropriate internal management staff regularly on progress of investigations and make recommendations for further initiatives such as new algorithms. Create, maintain and manage cases within the tracking system to ensure information is accurate and timely. Perform other duties as needed. REQUIRED QUALIFICATIONS: A Bachelors degree in Business administration, finance, public health or related field; or equivalent years of experience. 5-7 years of related experience in fraud examination, healthcare, business, finance or related field; with at least 2 years of experience conducting data mining in the healthcare insurance industry and claims related experience. Knowledge of coding, reimbursement and claims processing policies. Knowledge of the principles and practices of medical auditing. Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions. Knowledge of the law and regulations as it relates to fraud and fraud investigations. Must have a track record of producing high quality work that demonstrates attention to detail. Ability to multi-task, establish priorities and work independently to achieve objectives. Ability to function effectively under pressure. Proficient in Microsoft Office applications (Word, Excel, PowerPoint and Access) Excellent Customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments. Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor. Strong oral and written communication skills including internal and external presentations. PREFERRED QUALIFICATIONS: Prefer individual possessing any of the following certifications or licensure: CPC, or CPMA, RN/LPN Advanced Microsoft Excel software skills. Knowledge of State and federal regulations as they apply to public assistance programs Strong Decision making skills with the ability to investigate and weigh alternatives and select the appropriate course of action. Creative thinking skills with the ability to ask the needed “bigger- picture” questions that lead to process and team improvements. ** Hybrid requirement ** - Once a month on site. Posting Disclaimer This job posting outlines the primary responsibilities and qualifications for the role but is not intended to be an exhaustive list. Duties and expectations may evolve in response to the needs of the department and the broader institution. In alignment with our commitment to pay transparency, the base salary range for this position is listed above (exclusive of benefits and retirement). At UMass Chan Medical School, final base salary offers are determined based on a combination of factors, including your skills, education, and relevant experience. We also consider internal equity to ensure fair and consistent compensation across our teams. Please note that the range provided reflects the full base salary range for this position. Offers are typically made within the midrange to allow for future growth and development within the role. In addition to base pay, UMass Chan offers a comprehensive Total Rewards package, which includes paid time off, medical, dental, and vision coverage, and participation in a 401(a)-retirement plan, with the option to contribute to a voluntary 403(b) plan. UMass Chan welcomes all qualified applicants and complies with all state and federal anti-discrimination laws. #J-18808-Ljbffr