Senior Healthcare Fraud Investigator

Job Description

Position Summary

We are seeking a Senior Healthcare Fraud Investigator to support our program integrity efforts through hands-on investigation of potential fraud, waste, and abuse (FWA). This role is ideal for someone who thrives on digging into data, managing complex cases, and driving investigations from start to finish .

You’ll play a key role in identifying risk, analyzing claims activity, and supporting compliance with state and federal healthcare regulations—particularly within Medicaid programs.

Key Responsibilities

• Independently manage a caseload of fraud, waste, and abuse investigations from identification through resolution
• Analyze healthcare claims data to detect unusual billing patterns, trends, and potential fraud indicators
• Conduct detailed research and develop cases using data, documentation, and interviews
• Interview providers, members, and other parties to gather actionable information
• Prepare clear, comprehensive investigative reports and documentation suitable for internal review and external agencies
• Partner with compliance, legal, and external stakeholders to support investigations and reporting requirements
• Respond to requests for information from regulatory agencies and support audit activities
• Identify opportunities for overpayment recovery, cost savings, and risk mitigation
• Stay current on emerging fraud schemes, regulatory changes, and industry trends

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications:

• Bachelor level education - Required
• Minimum 5-7 years' experience in a healthcare program integrity position ensuring compliance with regulatory and contractual requirements. - Required
• Ability to work independently with minimal supervision, and manage a high volume of assignments
• High degree of integrity and confidentiality required handling information that is considered personal and confidential
• Analytical skills and ability to make deductions; logical and sequential thinker
• Strong verbal and written communication skills.
• Healthcare industry and/or Medicaid/CHIP knowledge required, healthcare claims knowledge and experience - Preferred .
• Knowledge and experience working on various approaches to healthcare fraud, waste, and abuse
• Working knowledge of Microsoft applications, Excel - Required .
• Knowledge of available resources (internal and external) to assist in investigations.
• Medical terminology knowledge and/or experience with CPT and ICD-10 coding - Preferred .
• Knowledge of suspected FWA trends, potential schemes, and matters of interest to law enforcement and regulators.
• Accredited Health Care Fraud Investigator (AHFI) and/or Certified Fraud Examiner (CFE) - Preferred
• Community Care Plan offers support for obtaining certification for qualified candidates.

SKILLS AND ABILITIES:

• Ability to communicate effectively, verbal and written
• Ability to self-motivate
• Strong time management skills
• Ability to prioritize and organize FWA program activities
• Ability to meticulously document case actions and findings for regulatory reporting and any legal action, if applicable
• Ability to collaborate
• Results oriented skills

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

Background Screening Notice:

In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at: h