Healthcare Fraud Investigator

Job Description:

• Identify and qualify 100%+ of budgeted leads each month (roughly 15), taking each from concept to an accepted lead.
• Earn at least 50% lead acceptance/concept approval from clients.
• Carry an active caseload of 20 to 30 cases per month, owning each case from open to close.
• Close 90% of individual cases within four to five months.
• Convert case value into recovered dollars, hitting at least 100% of your top-line revenue target (roughly 45% of identified value converting to gross revenue).
• Maintain a 95% first-time acceptance rate on documentation sent to customers.
• Keep payer complaints at zero and minimize provider abrasion across every interaction.
• Work fluently across Medicare, Medicaid, Commercial, and FEP lines of business.

Requirements:

• 2+ years at a healthcare payer or vendor as an Investigator or Auditor working with healthcare claims.
• Experience across multiple lines of business (Medicare, Medicaid, Commercial, FEP).
• Proficiency with auditing software, case management systems, and claims systems.
• Experience owning the full investigation workflow, from lead to revenue.
• Sound analytical judgment and the ability to negotiate favorable, defensible outcomes.
• U.S.-based with work authorization (no offshore; PHI environment).

Benefits:

• Health insurance
• 401(k) matching
• Paid time off
• Flexible work arrangements
• Professional development