Healthcare Fraud Investigator

Fraud Investigator – Special Investigations Unit Join our Special Investigations Unit (SIU) as a Healthcare Fraud Investigator , supporting our U.S. Commercial Healthcare business. In this role, you will conduct and support investigations and audits involving potentially fraudulent healthcare claim activity by providers and other parties. You will use investigative, analytical, and claims-auditing expertise to identify potential fraud, analyze complex information, document findings, and recommend appropriate corrective actions. Depending on investigative findings, recommendations may include recovery, referral for prosecution, litigation, or other actions. Key Responsibilities: Conduct and support investigations and audits involving suspected healthcare fraud and potentially fraudulent claim activity. Analyze claims, investigative findings, audit results, and other relevant information to identify patterns, discrepancies, and potential fraud. Prepare clear written investigative summaries, findings, and recommendations. Develop evidence packages for referral to third parties, including contract holders, state insurance fraud bureaus, and law enforcement agencies. Lead on-site inspections and conduct patient and provider interviews, as needed. Respond to subpoenas and information requests from law enforcement agencies and state Departments of Insurance. Represent the company as a witness in judicial proceedings, when appropriate. Support special projects requiring expertise in