Senior Investigator - Lead Validation (Healthcare FWA)
New
Based in the United StatesFull-TimeSenior
Salary$70,000 – $90,000 USD
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Job Details
- Experience
- 5–8 years
- Required Skills
- Data AnalysisData MiningMicrosoft Excel
Requirements
- Bachelor’s degree in a related field or equivalent combination of education and relevant professional experience.
- 5–8 years of experience in healthcare fraud, waste, and abuse investigations or related analytical/compliance roles.
- Advanced proficiency in Excel, including data analysis, pattern detection, and reporting.
- Strong experience in proactive data mining and investigative analysis within large datasets.
- Familiarity with sampling and extrapolation techniques (RAT-STATS experience preferred).
- Experience working with FWA or claims investigation tools (e.g., Sentinel, Commander, Informant or similar platforms) is a plus.
- Strong analytical thinking skills with exceptional attention to detail and accuracy.
- Excellent written and verbal communication skills, with the ability to present complex findings clearly.
- Strong organizational and multitasking abilities in a remote, deadline-driven environment.
- Preferred certifications such as AHFI, CFE, CFS, CHC, or CFI are a plus.
Responsibilities
- Identify, investigate, and evaluate potential cases of healthcare fraud, waste, and abuse using claims data, analytics tools, and investigative methodologies.
- Monitor provider behavior to detect anomalies, trends, and patterns that may indicate non-compliant or suspicious activity.
- Conduct advanced data analysis using Excel and other tools to support detection, validation, and escalation of potential FWA cases.
- Develop detailed investigative summaries and presentations outlining findings, conclusions, and recommended actions.
- Utilize sampling, data extrapolation techniques, and investigative frameworks to support case development and validation efforts.
- Collaborate with internal stakeholders and external partners, including legal teams and law enforcement, to support case resolution and proceedings when required.
- Deliver training and knowledge-sharing sessions related to investigative processes, fraud detection techniques, and compliance standards.
- Maintain up-to-date knowledge of healthcare regulations, coding guidelines, and fraud prevention best practices.
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