Fraud Investigator

Role: SIU Investigator Analyst

Location: Remote

Contract Duration: 4-month contract

Role Summary:

Senior analyst responsible for intake, triage, and regulatory reporting of all healthcare fraud, waste, and abuse (FWA) leads. Serves as the central coordinator for case intake, ensures timely compliance reporting, and provides analytical support for complex investigations. Acts as a Subject Matter Expert (SME) and mentor.

Core Responsibilities

Intake & Triage

• Oversee intake and prioritization of investigative leads (hotline, email, law enforcement, regulatory referrals)
• Evaluate and route cases to appropriate internal teams or partner organizations (PPs/PPGs)
• Document and track all cases in the HCFS case management system

Regulatory Reporting & Compliance

• Prepare and submit required reports to CMS and DHCS within strict timelines (e.g., 10-day requirement)
• Serve as primary point of contact for regulatory agencies
• Ensure adherence to federal/state reporting requirements and internal policies

Data Analysis & Investigation Support

• Analyze claims, provider data, and fraud indicators to identify suspicious patterns
• Support investigators with analytics and reporting for complex cases
• Apply knowledge of coding (CPT, HCPCS, ICD-10), fraud schemes, and reimbursement models

Systems & Process Ownership

• Serve as SME for HCFS and reporting systems, driving enhancements and system improvements
• Lead development and optimization of reporting functions and workflows

Leadership & SME

• Train and mentor junior staff on intake processes and reporting standards
• Provide guidance on fraud detection, regulatory compliance, and best practices

Qualifications

Education: Associate’s required (or equivalent experience); Bachelor’s preferred

Experience:

• 4 years in healthcare fraud investigation/detection
• Experience with Medi-Cal/Medicare/Medicaid reporting preferred

Skills

• Strong analytical and data interpretation skills
• Expertise in regulatory reporting and compliance requirements
• Advanced proficiency in Excel and familiarity with HCFS, HPMS, and other systems
• Knowledge of healthcare coding (CPT, HCPCS, ICD-10) and billing processes
• Strong project management, organization, and communication skills

Certifications (Preferred)

• Certified Medical Coder
• Accredited Healthcare Fraud Investigator (AHFI)

Bottom Line

Owns fraud case intake and regulatory reporting—ensuring compliance, enabling investigations, and driving data-driven insights across the SIU.