healthcare fraud investigator

GeoBlue

<div><div><div><div><div><h2 class="jobSectionHeader">THIS COMPANY WORKS IN</h2><h3 class="jobSectionHeader">
Healthcare, Insurance</h3></div><div><h2 class="jobSectionHeader">
COMPANY SIZE</h2><h3 class="jobSectionHeader">
Medium</h3></div></div></div></div><div><div><div>
Who we are 
 
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. 
 
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. 
 
Responsibilities: 
 
 
<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> 

Additional Responsibilities May Include: 
<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> 

Requirements: 
<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> 

What you'll get in return: 
<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> 

Other Great Perks: 
 
 
<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>

Global Healthcare Fraud Investigator

CVS Health

<div>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.
This position can be work from home anywhere in the United States.
Position Summary
We are seeking an experienced Senior Healthcare Fraud Investigator to join our Special Investigations Unit (Aetna SIU), Self-Funded investigations team.
In this role, you will manage complex investigations into suspected and known acts of healthcare fraud, waste and abuse (FWA).
Key Responsibilities
<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>Required Qualifications<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>
Preferred Qualifications<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>
Resident of North Carolina</li></ul>
Education<ul><li>
Bachelor's degree preferred or equivalent work experience.</li></ul>
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$46,988.00 - $112,200.00
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. 
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.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. 
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. 
Additional details about available benefits are provided during the application process and on Benefits Moments. 
We anticipate the application window for this opening will close on: 07/27/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Senior Investigator, Special Investigations Unit (Aetna SIU)

Centene

<div>You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility. 
Please note: this is a remote role with preference on candidates located in Texas.
Position Purpose: Investigate allegations of potential healthcare fraud and abuse activity. Assist in planning, organizing, and executing claims investigations or audits that identify, evaluate and measure potential healthcare fraud and abuse.<ul><li>
Conduct investigations of potential waste, abuse, and fraud</li><li>
Document activity on each case and refer issues to the appropriate party</li><li>
Perform data mining and analysis to detect aberrancies and outliers in claims</li><li>
Develop new queries and reports to detect potential waste, abuse, and fraud</li><li>
Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions</li><li>
Assist with complex allegations of healthcare fraud</li><li>
Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies</li><li>
Complete various special projects and audits</li><li>
Performs other duties as assigned.</li><li>
Complies with all policies and standards.</li></ul>
Education/Experience: 
Bachelor's Degree Business, Criminal Justice, Healthcare, or related field, or equivalent experience required. 1+ years Medical claim investigation, medical claim audit, medical claim analysis, or fraud investigation required.
Pay Range: $56,200.00 - $101,000.00 per year
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. 
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act</div>

SIU Investigator

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Global Healthcare Fraud Investigator

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Senior Investigator, Special Investigations Unit (Aetna SIU)

Senior Investigator, Special Investigations Unit (Aetna SIU)

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