Senior Fraud Investigator

Overview HCSC is seeking a dynamic individual to join its Fraud Investigations team. The role plans and develops investigative tools and techniques to conduct detailed investigations of potentially fraudulent claim activity by members, employees, and providers, both internally and externally. It also reviews operational controls, claim system controls, and protocols, and recommends enhancements to reduce the potential for fraud. The position is hybrid/flex, requiring in‑office presence three days per week; relocation and sponsorship are not offered. Responsibilities Plan and develop investigative tools and techniques for fraud detection. Conduct detailed investigations of potentially fraudulent claim activity. Review and recommend operational and system controls to mitigate fraud risk. Analyze claim payment data and prepare evidentiary reports. Monitor fraudulent claims, suspect billing patterns, and related business matters. Develop criminal and civil cases and organize preparation of cases for prosecution or litigation. Prepare accurate written reports of interviews and documentation, reflecting investigative activity. Qualifications Bachelor’s Degree. Three (3) years of healthcare fraud investigative experience OR five (5) years of law enforcement experience (local, state, or federal). Familiarity with laws applicable to health care fraud. Ability to develop effective liaison relationships to facilitate case identification, investigation, and prosecution. Strong verbal and written communication skills. Proficiency with MS Office (Word, Excel, PowerPoint) and Workday. Preferred Qualifications Certified Professional Coder. Certified Fraud Examiner. Accredited Health Care Fraud Investigator. Knowledge of health care claims processing and benefits administration. Benefits Health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, and other incentives. For more information, visit Pay Base Pay Range: $55,900.00 – $123,500.00 (exact compensation varies by skills, experience, and location). EEO Statement HCSC is an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. #J-18808-Ljbffr Health Care Service Corp.