Health Fraud Investigator

Security, Manager, Director, CMS, Computer
Full Time

Job Description

Health Fraud Investigator
FL, Weston 33331

Security Clearance: U.S. Citizen

Skills: Certified Fraud Examiner, Accredited Healthcare Anti-Fraud Investigator, law enforcement, Medicare, Medicaid, healthcare fraud

Location Note: This position offers a tele-work schedule and permits work from any U.S. based location.
Telework Requirements: Remote work environment should be conducive to making phone calls, attending teleconferences, and communicating with external team members and the general public as part of the everyday job duties.

Travel Note: There is a potential for limited travel to conduct field work post COVID-19. The travel requirements, if any, are undetermined at this time.

This is a 1099 opportunity with the potential to convert to full-time/W2 employment in the future.

We are recruiting for a Health Fraud Investigator with a Certified Fraud Examiner or Accredited Healthcare Anti-fraud Investigator background to support claims for review for Medicare, Medicaid, and other claims data. Qualified candidates will have experience conducting in-depth evaluation of claims and making field level judgments related to investigations for potential Medicaid and/or Medicare fraud, waste and abuse investigations. This position requires knowledge of acceptable criteria for referral to the Centers for Medicare and Medicaid for administrative action or to the OIG for criminal action.

Role and responsibilities include:
  • Utilizing leads provided by the investigative team and referrals from government and private agencies, works with the team to prioritize complaints for investigation, and then investigates, conducts interviews and reviews information to make potential fraud determination.
  • Determining investigation or case appropriateness of fraud, waste and abuse issues in accordance with pre-established criteria.
  • Reviewing and referring potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee.
  • Conducting interviews of witnesses, informants, and subject area experts and targets of investigations.
  • Maintaining information files and chain of evidence (identifying, collecting, preserving) and analyzing and summarizing evidence for supporting documentation of claims.
  • Examining records, verifying authenticity of documents, and providing information to support the preparation of attestations/referrals or supervising the preparation of attestations/referrals, as needed.
  • Drafting investigation reports, evaluates investigation reports, and promotes effective and efficient investigations.
  • Initiating and maintaining communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.
  • Testifying at various legal proceedings, as necessary.
  • Identifying opportunities to improve processes and procedures.
  • Providing a high level of customer service with internal and external communications.

Requirements include:
  • U.S. citizenship with ability to pass a pre-employment background investigation.
  • Bachelor's degree.
  • Certification or formal training in one or more of these areas:
    • Certified Fraud Examiner or related certification
    • Accredited Healthcare Anti-Fraud Investigator Certification or related certification
    • Successful completion of a law enforcement academy
  • Experience in healthcare fraud investigation/detection.
  • Experience supporting a state or federal program conducting healthcare fraud investigations.
  • Expertise in reviewing and analyzing investigation data and make determinations.
  • Experience working with CMS, State Medicaid, OIG/FBI, or similar agency.
  • Commitment to providing excellent customer service communicating with internal and external customers including the general public.
  • Computer skills and experience with computer data entry and reporting systems.
  • Experience working with different software applications and ability to quickly learn and use new systems.
  • Ability to process information and use apply basic math concepts.
  • Ability to problem solve and provide resolution for complex issues.
  • Experience working with information from multiple sources and ability to communicate with team members to receive and convey information in different formats including written, oral, diagrams, schedules, and forms.
  • Demonstrated ability to work independently, follow processes and instructions, manage workload, and provide regular status/updates to supervisor(s).
  • Ability to effectively communicate information with team members and others, as required.
  • Experience reading, analyzing, and interpreting information and preparing reports and other business correspondence.
  • Experience responding to inquiries and providing information and resolution.
  • Reliable internet connectivity.
  • Valid U.S. state driver's license.
  • Ability to travel, if required. Travel requirements are expected to be minimal and at this time are undetermined based on COVID-19 restrictions.



Tallon Recruiting and Staffing provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

We comply with Form I-9 identity and legal work authorization requirements and utilize E-Verify for Employment Eligibility Verification in accordance the Immigration Reform and Control Act of 1986 (IRCA).

Individuals with disabilities who need assistance with the application process can reach us by email at or telephone 571-333-2151.

For more information please visit us at .
Dice Id : 10191119
Position Id : 782
Originally Posted : 1 year ago
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