Investigator II

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Investigator II is responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. How You Will Make An Impact Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims.Responsible for identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company’s health plan, line of business and/or state. Effectively establish rapport and on-going working relationship with law enforcement.May interface internally with Senior level management and legal department throughout investigative process.May assist in training of internal and external entities.Assists in the development of policy and/or procedures to prevent loss of company assets. Minimum Requirements: Requires a BA/BS and minimum of 3 years related experience; or any combination of education and experience, which would provide an equivalent background. Preferred Skills, Capabilities And Experiences Advanced Excel proficiency; ability to run pivot tables and analyze large datasets.Familiarity with CPT coding.Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.Investigative experience preferred (e.g. health insurance, law enforcement).