Senior Healthcare Fraud Investigator

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 finishYou'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 ResponsibilitiesIndependently manage a caseload of fraud, waste, and abuse investigations from identification through resolutionAnalyze healthcare claims data to detect unusual billing patterns, trends, and potential fraud indicatorsConduct detailed research and develop cases using data, documentation, and interviewsInterview providers, members, and other parties to gather actionable informationPrepare clear, comprehensive investigative reports and documentation suitable for internal review and external agenciesPartner with compliance, legal, and external stakeholders to support investigations and reporting requirementsRespond to requests for information from regulatory agencies and support audit activitiesIdentify opportunities for overpayment recovery, cost savings, and risk mitigationStay current on emerging fraud schemes, regulatory changes, and industry trendsThis 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 RequiredMinimum 5-7 years' experience in a healthcare program integrity position ensuring compliance with regulatory and contractual requirements. RequiredAbility to work independently with minimal supervision, and manage a high volume of assignmentsHigh 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 PreferredKnowledge and experience working on various approaches to healthcare fraud, waste, and abuseWorking knowledge of Microsoft applications, Excel RequiredKnowledge of available resources (internal and external) to assist in investigations.Medical terminology knowledge and/or experience with CPT and ICD-10 coding PreferredKnowledge 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) PreferredCommunity Care Plan offers support for obtaining certification for qualified candidates.SKILLS AND ABILITIES:Ability to communicate effectively, verbal and writtenAbility to self-motivate Strong time management skillsAbility to prioritize and organize FWA program activitiesAbility to meticulously document case actions and findings for regulatory reporting and any legal action, if applicableAbility to collaborate Results oriented skillsPHYSICAL 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

Created: 2026-05-11