Medicaid Fraud Investigator

Job Description

Job Description

Medicaid Fraud Investigator – Special Investigations Unit (SIU)

Location: [Remote - ideally in the Chicago area]

Job Type: Full-time/Contract

Level: Associate

Put your passion where it meets purpose! We attract some of the brightest minds in healthcare. Surround yourself with talented, driven colleagues who share a passion for better health outcomes and a more connected care journey.

Our Special Investigations Unit (SIU) works directly with health plan clients to identify, reduce, and eliminate healthcare fraud, waste, and abuse (FWA). As an SIU Investigator, you won't just analyze data—you’ll actively protect healthcare integrity through collaborative, high-impact investigations.

As a key member of our SIU, you will work closely with our Operations, Compliance, and Utilization Management teams, as well as partners in State Agencies and Law Enforcement. You will collaborate with a dynamic team of investigators to uncover current fraud schemes, perform data analytics, conduct audits, and educate healthcare providers.

• 1–2 years of FWA investigative experience within a healthcare operation.

• Solid understanding of corporate investigative practices and medical terminology, human anatomy, tests, and procedures.

• Demonstrated ability to manage multiple cases simultaneously while meeting tight turnaround times with accuracy and detail.

• solid leadership, problem-solving, and decision-making skills with excellent written/verbal communication.

• Proficiency with MS Office (Word, Excel, Outlook, PowerPoint) in a Windows environment.

• Familiarity with CMS, Medicaid, Medicare, or commercial insurance regulations.

• 3–5 years of healthcare FWA investigative experience.

• Knowledge of healthcare coding, claims billing, Managed Care, Benefit Design, and Federal Regulations.

• Professional certifications such as AHFI, CFE, or coding certifications (CPC, CCS, CMPA).

If you are detail-oriented, adaptable, and passionate about keeping healthcare fair and accessible, we want to hear from you!

Apply today to join our team!

Responsibilities

• Investigative Operations & Audits: Perform targeted claim audits (desk and on-site), conduct data analysis, review records, perform provider office inspections, and handle field observations/interviews.

• Analysis & Reporting: Utilize data systems and audit methodologies to spot trends, patterns, and anomalies. Prepare clear, actionable investigation reports and audit summaries for leadership, state/federal regulatory entities, and external partners.

• Hotline & Case Management: Manage FWA hotline calls and emails, tracking inquiries and keeping precise, up-to-date documentation in the Investigation Database within strict turnaround times.

• Education & Prevention: Recommend preventive measures and process improvements based on case outcomes. Assist in developing and delivering FWA training across the organization, acting as an SIU Liaison to assigned departments.

• Policy & Compliance: Assist in developing FWA policies and procedures, ensuring absolute confidentiality and compliance with CMS, Medicaid, Medicare, and commercial insurance standards.

• Fraud Investigation
• Medicare/Medicaid
• Certified Fraud Examiner

Qualifications
• Years of experience: 2 years
• Experience level: Experienced

Randstad is a world leader in matching great people with great companies. Our experienced agents will listen carefully to your employment needs and then work diligently to match your skills and qualifications to the right job and company. Whether you're looking for temporary, temporary-to-permanent or permanent opportunities, no one works harder for you than Randstad.

Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.
At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact View email address on ziprecruiter.com.
Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).
This posting is open for thirty (30) days.
It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.