Healthcare Fraud Investigator
About the role
Integrity Advantage is a specialized healthcare consulting firm that helps payers and government entities combat fraud, waste, and abuse through expert investigation, medical review, and payment integrity services. Led by seasoned industry professionals, the organization offers vendor-neutral guidance grounded in decades of hands-on experience across diverse healthcare plans. Core services include program assessments, operational FWA support and SIU outsourcing, medical record review, and comprehensive training and mentorship. Dedicated medical review and investigations teams apply strict privacy standards, robust sampling methodologies, and detailed documentation to support accurate findings and recovery efforts. As a certified Women's Business Enterprise (WBE) and Economically Disadvantaged Woman-Owned Small Business (EDWOSB), Integrity Advantage is committed to innovation and advanced analytics in healthcare fraud prevention.
Responsibilities
- Identify, investigate, and document potential healthcare fraud, waste, and abuse across various payer programs
- Review claims and medical records, conducting data analysis to detect anomalies and outliers
- Develop leads for potential overpayments or non-compliant patterns
- Perform interviews with providers and members
- Prepare clear investigative reports, summarizing findings and recommending corrective actions or referrals to law enforcement when warranted
- Collaborate closely with medical review, analytics, and compliance teams to support SIU operations, recovery efforts, and program integrity initiatives
- Contribute to continuous process improvement
- Assist with training and mentoring as needed
- Ensure all work adheres to regulatory, privacy, and ethical standards
Qualifications
- Strong investigative and analytical skills, including experience with claim review, lead generation, and fraud, waste, and abuse detection
- Ability to interpret medical records, coding, and billing practices; familiarity with DRG, professional, and inpatient claims is highly beneficial
- Knowledge of healthcare regulations, payer policies, and compliance requirements related to SIU operations and payment integrity
- Proficiency with data analysis tools, spreadsheets, and reporting platforms to support statistically valid sampling and trend identification
- Excellent written and verbal communication skills for drafting investigative reports, documenting findings, and conducting interviews
- Demonstrated ability to work independently in a remote environment, manage competing priorities, and meet deadlines with attention to detail
- Bachelor's degree in healthcare administration, criminal justice, nursing, business, or a related field; equivalent experience may be considered
- Relevant certifications such as AHFI, CPC, CPMA, CFE, RN, or other healthcare fraud, coding, or compliance credentials are a plus
- Experience collaborating with payers, government entities, or law enforcement on healthcare fraud investigations