Fraud Investigator

Senior analyst responsible for intake, triage, and regulatory reporting of all healthcare fraud, waste, and abuse (FWA) leads. Serves as the central coordinator for case intake, ensures timely compliance reporting, and provides analytical support for complex investigations. Acts as a Subject Matter Expert (SME) and mentor. Core Responsibilities Intake & Triage Oversee intake and prioritization of investigative leads (hotline, email, law enforcement, regulatory referrals) Evaluate and route cases to appropriate internal teams or partner organizations (PPs/PPGs) Document and track all cases in the HCFS case management system Regulatory Reporting & Compliance Prepare and submit required reports to CMS and DHCS within strict timelines (e.g., 10-day requirement) Serve as primary point of contact for regulatory agencies Ensure adherence to federal/state reporting requirements and internal policies Data Analysis & Investigation Support Analyze claims, provider data, and fraud indicators to identify suspicious patterns Support investigators with analytics and reporting for complex cases Apply knowledge of coding (CPT, HCPCS, ICD-10), fraud schemes, and reimbursement models Systems & Process Ownership Serve as SME for HCFS and reporting systems , driving enhancements and system improvements Lead development and optimization of reporting functions and workflows Leadership & SME Train and mentor junior staff on intake processes and reporting standards Provide guidance on fraud detection, regulatory compliance, and best practices Qualifications Education Associate’s required (or equivalent experience); Bachelor’s preferred Experience 4+ years in healthcare fraud investigation/detection Experience with Medi-Cal/Medicare/Medicaid reporting preferred Skills Strong analytical and data interpretation skills Expertise in regulatory reporting and compliance requirements Advanced proficiency in Excel and familiarity with HCFS, HPMS, and other systems Knowledge of healthcare coding (CPT, HCPCS, ICD-10) and billing processes Strong project management, organization, and communication skills Certifications (Preferred) Certified Medical Coder Bottom Line Owns fraud case intake and regulatory reporting—ensuring compliance, enabling investigations, and driving data‑driven insights across the SIU. #J-18808-Ljbffr Insight Global