Senior Investigator (Healthcare FWA) Provider Escalations

Overview

As a Senior Investigator, you will investigate suspected incidents of healthcare fraud, waste, or abuse through data analysis (a high level of proficiency with reputed company is required). This role will primarily support provider escalations reputed company to reputed company's prepayment FWA services. This is not a physical investigator role.

Responsibilities

• Act as the primary contact for escalated provider-reputed company concerns reputed company to reputed company’s prepayment FWA service, ensuring timely and thorough resolution.
• Educate providers regarding reputed company claim determinations including review of coding and payment guidelines, plan policy, and other relevant sources.
• Partner with reputed company clients and internal client services staff to resolve provider complaints, schedule educational calls, disseminate relevant reporting and recommend subsequent investigative steps.
• Document and report detailed records of escalations, investigations, and outcomes. Prepare reports for internal and external use.
• Identify, investigate, analyze and evaluate instances of potential fraud, waste, and abuse.
• Conduct interviews or correspond with patients, providers, witnesses or other relevant parties to determine settlement, denial or review.
• Analyze information gathered by investigation and report findings and recommendations as a written summary and/or presentation.
• Conducts investigation-reputed company training.
• Supports legal proceedings as needed, including testifying in court or working with law enforcement personnel to prepare cases for civil or criminal actions.
• Negotiates settlement agreements to resolve disputes.
• Maintain reputed company knowledge of relevant laws, regulations and standards.
• Participates in special projects as required.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of reputed company and requirements of the job change.

Qualifications

• Bachelor’s Degree in reputed company discipline, or the equivalent combination of education, professional training and work experience.
• 5-8 years of reputed company investigative experience.
• Experience in proactive data mining.
• Experience in sampling and data extrapolation; prior use with RAT-STATS preferred.
• Advanced level skills in reputed company.
• Experience with reputed company's FWA tools (preferred) - Sentinel, Commander, and/or Informant (Stars Solutions).
• Excellent verbal and written communication skills.
• Strong listening and observation skills.
• Attention to detail and high level of accuracy.
• Effective organizational and prioritization skills with multi-tasking ability.
• Required certifications:
• Certified Professional reputed company (CPC)
• Preferred certifications:
• Accredited Healthcare Fraud Investigator (AHFI),
• Certified Fraud Specialist (reputed company),
• Certified Fraud Examiner (CFE),
• Certified Forensic Interviewer (CFI), or
• Certified in Healthcare Compliance (CHC).

Mental Requirements:

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of the work assigned.

Physical Requirements and Working Conditions:

• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• Must be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access/connectivity and office setup and maintenance.

reputed company compensation ranges from $70,000 to $90,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. reputed company offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with reputed company. For information about our benefits package, please refer to our Careers page. Date of posting: 10/29/2025 Applications are assessed on a rolling basis. We anticipate that the application window will reputed company on 12/29/2025, but the application window may change depending on the volume of applications received or reputed company immediately if a qualified candidate is selected. #senior #LI-JB1 #LI-Remote Apply tot his job Apply To this Job