Senior Investigator- Special Investigations Unit

Company Overview: Health Network One (HN1) partners with health plans and providers to modernize how specialty care is delivered and managed, reducing complexity, driving better performance, and improving lives.

With over 30 years of experience, Health Network One advances care in several unique specialties: Total Eye, Sleep Well, Pure Derm and Thrive Therapy. By curating specialty networks and credentialing providers who meet rigorous access and quality standards, we bring together value-based models and clinical expertise to ensure providers thrive, payers succeed, and members receive the high-quality care they deserve.

Position Summary: Health Network One is seeking a highly motivated and experienced Senior Investigator to join our Special Investigations Unit. This role is critical in supporting our ongoing efforts to identify, investigate, and resolve instances of fraud, waste, and abuse (FWA) within our provider networks and across healthcare operations. The Senior Investigator will lead complex investigations, ensure regulatory compliance, and work closely with internal teams and external partners to uphold the integrity of our healthcare delivery systems.

Key Responsibilities

• Lead and manage end-to-end investigations related to potential FWA activities within the provider network, claims submissions, or member services.
• Analyze claims data, provider billing patterns, and clinical documentation to identify anomalies and potential violations.
• Conduct interviews, gather evidence, and prepare clear, detailed investigative reports.
• Coordinate with internal departments including Compliance, Legal, Clinical Management, Provider Relations, and IT for case development and resolution.
• Collaborate with external regulatory bodies, Special Investigation Units (SIUs), and law enforcement as needed.
• Support regulatory reporting requirements and assist in the preparation of documentation for CMS, OIG, and state agencies.
• Recommend corrective actions, including provider education, recoveries, or referrals for legal or regulatory action.
• Assist in the development and delivery of FWA training for staff and providers.
• Monitor industry trends, emerging schemes, and best practices to proactively enhance FWA detection capabilities.
• Maintain accurate documentation and case tracking in accordance with company policies and regulatory requirements.

Qualifications:

• Bachelor's degree required; Master’s degree or professional certification (e.g., CFE, AHFI, CHC) preferred.
• Minimum of 5-7 years of experience in healthcare fraud investigations, compliance, or related field.
• Deep understanding of federal and state healthcare regulations, including Medicare and Medicaid rules, HIPAA, and CMS requirements.
• Strong knowledge of healthcare claims processing, billing and coding practices, and managed care operations.
• Experience working with data analytics tools and investigative software (e.g., SAS, SQL, Excel).
• Excellent analytical, communication, and report-writing skills.
• Ability to handle sensitive information with discretion and maintain confidentiality.
• Proven ability to manage multiple investigations simultaneously and meet deadlines.

Preferred Experience:

• Prior experience working in or with a Managed Care Organization (MCO) or Third-Party Administrator (TPA).
• Familiarity with provider network operations and credentialing.
• Background in healthcare legal/compliance.