fraud investigator

GeoBlue

<div><div><div><div><div><h2 class="jobSectionHeader"><b>THIS COMPANY WORKS IN</b></h2><h3 class="jobSectionHeader"><b>
Healthcare, Insurance</b></h3></div><div><h2 class="jobSectionHeader"><b>
COMPANY SIZE</b></h2><h3 class="jobSectionHeader"><b>
Medium</b></h3></div></div></div></div><div><div><div><p><b>
Who we are</b><br>
<br>
At Blue Cross Blue Shield Global SolutionsSM (BCBS Global SolutionsSM), we make it easy for people and organizations to access and pay for healthcare abroad. By combining digital innovation with human-centered care, we go above and beyond for our customers and deliver an international healthcare experience that's simple, efficient, and human. Whether our customers live, work, travel or study abroad, we give them the confidence and peace of mind to embrace every journey and say &quot;yes&quot; to new possibilities.<br>
<br>
The Fraud Investigator is on the front line of the company's effort to reduce unnecessary medical costs and make healthcare more affordable for our customers around the globe. The investigator is responsible for the end-to-end investigation process on known or suspected acts of fraud and abuse on healthcare claims around the globe, from information gathering and interviews to financial recoveries and law enforcement collaboration.<br>
<br>
<b>Responsibilities:<br>
</b><br>
<br>
</p><ul><li>Evaluate and gather information related to cases of known or suspected fraud.
</li><li>Analyze historic claims to determine the full scope of identified fraudulent activity.
</li><li>Develop an investigation strategy for each case to assist in timely and successful resolution.</li><li>
Conduct interviews/interrogations with customers, providers, witnesses, authorities, and other people involved in the case.
</li><li>Document your activities in a logical, clear, and concise format, concluding with a comprehensive written investigation report.</li><li>
Facilitate the recovery of fraud and abuse related over payments of company and customer funds.
</li><li>Collaborates with law enforcement agencies as appropriate, including potentially testifying to investigation details in court.
</li><li>Researches and prepares information for management and client reporting.</li><li>
Coordinate activities across other departments (ex. Clinical, Legal, Provider Finance,Global Service Center, Claims) and external entities (ex. BlueCross Blue Shield home plans, law enforcement).</li><li>
Partner with legal and compliance to ensure all state, federal, and international requirements for investigations and fraud reporting are adhered to.
</li><li>Identify and deliver on continuous improvement opportunities.</li></ul><br>
<b>
Additional Responsibilities May Include:</b><br>
<ul><li>
Develop process documentation for new and existing processes.
</li><li>Develop and deliver training to internal and external teams.
</li><li>Partner with IT to develop new and enhanced tools for fraud detection and investigation workflow management.</li><li>
Other duties as assigned.</li></ul><br>
<b>
Requirements:</b><br>
<ul><li>
College degree or equivalent experience required.</li><li>
Fraud examination certification or equivalent credentials highly valued.</li><li>
Minimum 2 years of investigation experience or 4 years of insurance industry experiencerequired;5-7years preferred.
</li><li>Demonstrated experience conducting international health insurance fraud investigations strongly preferred.
</li><li>Strong attention to detail and problem-solving skills.</li><li>
Excellent written and verbal communication skills.
</li><li>Strong organizational skills, with the ability to manage multiple competing tasks at the same time.</li><li>
Ability to manage ambiguity and drive for resolution.</li><li>
Multilingual strongly preferred.</li><li>
Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).</li></ul><br>
<b>
What you'll get in return:</b><br>
<ul><li>
Competitive annual salary based on experience within a similar role</li><li>
Annual bonus</li><li>
Competitive medical plans</li><li>
Telemedicine available</li><li>
Paid parental leave</li><li>
Employee assistance and wellness support 24/7</li><li>
Free international healthcare coverage</li></ul><br>
<b>
Other Great Perks:<br>
</b><br>
<br>
<ul><li>Hybrid work model</li><li>
Work abroad arrangements available
</li><li>Generous PTO accrual program with carry-over option</li><li>
9 paid holidays in addition to one floating holiday and one volunteer day</li><li>
Tuition reimbursement</li><li>
Career/Learning and development opportunities</li><li>
401(k) with generous company match</li><li>
Pet insurance offerings</li><li>
Identity theft and legal coverages available
</li><li>Emphasis on well-being (Virtual well-being platform, monthly mindfulness events, and giveaways)</li></ul></div></div></div></div><p></p>

Global Healthcare Fraud Investigator

Kemper

<div><p>Location(s)</p>
Tampa, Florida<p></p><p><b>
Details</b></p><p></p><p><i>
Kemper is one of the nation&rsquo;s leading specialized insurers. Our success is a direct reflection of the talented and diverse people who make a positive difference in the lives of our customers every day. We believe a high-performing culture, valuable opportunities for personal development and professional challenge, and a healthy work-life balance can be highly motivating and productive. Kemper&rsquo;s products and services are making a real difference to our customers, who have unique and evolving needs. By joining our team, you are helping to provide an experience to our stakeholders that delivers on our promises.
</i></p><p></p><p><b>Position Summary:</b></p><p></p><p>
The SIU Investigator will conduct field as well as desk investigations of insurance claims referred to and accepted for investigation by the Special Investigative Unit. Our Special Investigator will function as a remote investigator working from her/his residence and servicing the Tampa and surrounding areas. Basic functions include: Investigation of claims, analysis and development of facts and evidence, and conducting and/or directing Examinations Under Oath. This investigator will coordinate investigations with outside SIU contacts, the Department of Insurance Fraud Division, NICB, and various law enforcement agencies. A laptop computer, cell phone and digital camera, MP3 recorder and other office equipment will be provided. Applicants must have the ability to travel.</p><p></p><p><b>
Position Responsibilities:
</b></p><ul><li>Attends necessary training schools and participates in training to develop and improve skills, develops contacts, and meets state regulatory educational requirements.</li><li>
Investigates files by using appropriate field, computer and telephone investigative techniques and provides appropriate documentation of actions in a thorough timely manner.</li><li>
Maintains a diary system on all assigned files. Diary system is to be worked so that the tempo is sufficient to assure prompt and timely recommendations.</li><li>
Prepares necessary reports for state fraud bureaus and cooperates with state agencies as required by law and management. Keeps the Special Investigation Unit and field managers advised of all critical situations.</li><li>
Reports findings of all investigations and makes recommendations to the responsible manager or other designee in a timely manner to facilitate prompt decisions.</li><li>
Develops and maintains contacts with other special investigative units and fraud related organizations.</li><li>
Acquires and maintains current knowledge in all appropriate jurisdictions regarding changes in law to ensure operations are within proper parameters established by law.</li></ul><p></p><p><b>
Position Qualifications:</b></p><ul><li>
College Degree or equivalent work experience.</li><li>
Three years of insurance claims investigation experience or professional investigation experience with law enforcement agencies; or</li><li>
Five years of professional investigation experience involving economic or insurance related matters; or an authorized medical professional to evaluate medical related claims.</li><li>
Must have a working knowledge of Digital photo and document metadata and have experience with using the internet and social networking for investigative purposes.</li><li>
The candidate must possess knowledge of the principles of casualty insurance and the auto casualty claims adjustment process.</li><li>
Investigative and legal expertise needed for this position.</li><li>
Completion of the NICB Basic and/or Advanced Academies and the Reid Interviewing and Interrogation Courses are desirable.</li><li>
Must have excellent communication skills and thorough working knowledge of Microsoft office applications.</li><li>
Must demonstrate a thorough knowledge of the workings of related state and federal agencies. The SIU investigator must possess oral and written communications skills and promote a favorable company image to the public.</li><li>
Fraud Claims Law Specialist (FCLS) or Fraud Claims Law Associate (FCLA) designations and Certified Insurance Fraud Investigator (CIFI) or Certified Fraud Examiner (CFE) designations are preferred.</li><li>
A valid driver&rsquo;s license and clean driving record is required.</li></ul><p></p><p>
Kemper is proud to be an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, disability status or any other status protected by the laws or regulations in the locations where we operate. We are committed to supporting diversity and equality across our organization and we work diligently to maintain a workplace free from discrimination.<br>
<br>
Kemper does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of Kemper and Kemper will not be obligated to pay a placement fee.</p><p></p><p><i>
Kemper will never request personal information, such as your social security number or banking information, via text or email. Additionally, Kemper does not use external messaging applications like WireApp or Skype to communicate with candidates. If you receive such a message, delete it.</i></p></div><p></p>

Field SIU Investigator - Tampa

CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p>
This position can be work from home anywhere in the United States.</p><p></p><p><b>
Position Summary</b></p><p>
We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), Self-Funded investigations team.</p><p>
In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).</p><p></p><p><b>
Key Responsibilities
</b></p><ul><li>Conduct high level, complex investigations of known or suspected acts of healthcare fraud, waste and abuse.
</li><li>Conduct Investigations to prevent payment of suspect or fraudulent claims submitted by insured's, providers, claimants, and customers.</li><li>
Research and prepare cases for clinical and legal review.</li><li>
Document all appropriate case activity in case tracking system.</li><li>
Prepare written case summaries and make referrals to State and Federal Agencies within the timeframes required by Law.
</li><li>Facilitate the recovery of company and customer money lost as a result of fraud, waste and abuse.
</li><li>Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud.
</li><li>Demonstrate high level of knowledge and expertise during interactions with internal and external partners.
</li><li>Provide trial testimony in support of criminal or civil proceedings.</li><li>
Give frequent presentations to internal and external customers regarding ongoing case investigations.</li><li>
Respond quickly and accurately to questions and leads from internal and external customers.</li><li>
Exercises independent judgment and uses available resources and technology to develop evidence in support of case investigations.
</li></ul><p></p><p><b>Required Qualifications</b></p><ul><li>
3-5 years investigative experience in the area of healthcare fraud, waste and abuse.</li><li>
Experience in in Microsoft Word, Excel, and Outlook products, open source database search tools, social media and internet research.
</li><li>Ability to travel approximately 10% of time for business purposes.</li></ul><p></p><p><b>
Preferred Qualifications</b></p><ul><li>
Certified Professional Coder (CPC), AHFI, CFE
</li><li>Knowledge of CVS/Aetna's policies and procedures</li><li>
Understanding of self-funded insurance plan operations</li><li>
Strong communication and customer service skills and the ability to effectively interact with Aetna's customers</li><li><p>
Resident of North Carolina</p></li></ul><p></p><p><b>
Education</b></p><ul><li>
Bachelor's degree preferred or equivalent work experience.</li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$46,988.00 - $112,200.00<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
We anticipate the application window for this opening will close on: 07/27/2026<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Senior Investigator, Special Investigations Unit (Aetna SIU)

Insight Service Group, ISG

<div><div><div><b>About Us:</b><br>
Insight Service Group (ISG) is a national investigative services firm specializing in cost containment and anti-fraud related services. We provide comprehensive solutions that help our clients mitigate risk and enhance their operational integrity.</div></div><div><div><b>
Surveillance Investigator Job Description:</b><br>
ISG is currently seeking experienced and motivated individuals for Surveillance Investigator positions. The ideal candidate will possess a strong work ethic, be self-motivated, and excel in problem-solving while working as part of a team. Candidates must be able to work independently, demonstrate strong time management, and possess excellent communication skills. Flexibility in scheduling is essential, as hours may include early mornings, weekdays, weekends, and evenings.</div></div><div><div><b>
Key Responsibilities as a Surveillance Investigator:</b></div></div><ul><li><div>
Conduct thorough investigations related to suspected fraud and misconduct.</div></li><li><div>
Perform on-site mobile surveillance, maintaining discretion and professionalism.</div></li><li><div>
Remain in the vehicle for extended periods (up to 8 hours or longer) while monitoring subjects.</div></li><li><div>
Travel up to 2 hours one way per case as needed.</div></li><li><div>
Document findings by writing detailed reports and uploading video evidence.</div></li><li><div>
Collaborate with team members and report findings to management.</div></li><li><div>
Maintain accurate records and documentation in compliance with company policies.</div></li></ul><div><div><b>
Surveillance Investigators must have the following qualifications:</b></div></div><ul><li><div>
Insurance Experience, Worker's Compensation, Auto, Liability, or similar SIU / Surveillance experience.</div></li><li><div>
A reliable vehicle, computer, and cell phone.</div></li><li><div>
A digital video camera with date and time stamp capability</div></li><li><div>
Be proficient in web-based systems, and ability to write detailed reports.</div></li><li><div>
Ability and willingness to travel as necessary.</div></li><li><div>
Ability to work independently and complete cases successfully with little supervision.</div></li></ul><div><div><b>
Additional Requirements</b></div></div><ul><li><div>
Need to maintain a minimum auto insurance coverage of <b>$150,000 / $250,000</b></div></li><li><div>
Must maintain a valid, unrestricted driver&rsquo;s license</div></li><li><div>
Must provide a copy of a recent driver history report</div></li><li><div>
Ability to show documentation for both prior to hire</div></li></ul><div><div>
We are hiring employees not subcontractors.</div></div><div><div><b>
***Current Florida Class C Private Investigator License Required***</b></div></div><div><div>
Florida Agency License #A2900064</div></div></div>

Florida, Fort Pierce Surveillance Investigator PT

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Global Healthcare Fraud Investigator

Field SIU Investigator - Tampa

Senior Investigator, Special Investigations Unit (Aetna SIU)

Senior Investigator, Special Investigations Unit (Aetna SIU)

Senior Investigator, Special Investigations Unit (Aetna SIU)

Senior Investigator, Special Investigations Unit (Aetna SIU)

Florida, Fort Pierce Surveillance Investigator PT