Job Description

Role Description The Investigator will perform detailed reviews of healthcare claims, medical records, and billing data to identify potential fraud, waste, and abuse, as well as compliance issues. This full-time remote role involves gathering and verifying documentation, applying relevant regulations and citation guidebooks, analyzing patterns and anomalies using data-driven methods, and preparing clear, comprehensive reports. The Investigator will collaborate with internal audit, legal, and client teams to build cases, summarize findings, and support overpayment recovery and corrective actions. Daily responsibilities include documenting investigative steps, maintaining strict confidentiality, adhering to ethical and HIPAA standards, and participating in quality assurance checks to ensure accuracy and consistency of results. The role may also support expert witness preparation, corporate integrity agreements, and ongoing improvement of audit and investigation methodologies.

Qualifications

• Investigative and analytical skills, including experience reviewing medical records, claims, and billing data for accuracy, compliance, and potential fraud.
• Knowledge of healthcare regulations and standards, such as HIPAA requirements, OIG guidance, payer policies, and citation or coding reference materials.
• Experience with audit processes, including sampling methodologies, documentation of findings, report generation, and quality assurance review.
• Data analysis capabilities, preferably with exposure to large data sets, pattern identification, and the use of tools or software to support audit and investigation work.
• Strong written and verbal communication skills for preparing clear reports, summarizing complex findings, and collaborating with clients and internal teams.
• High level of integrity, professionalism, and objectivity, with a commitment to ethical conduct and strict confidentiality when handling PHI and sensitive information.
• Ability to work independently in a remote environment, manage multiple cases or projects, and meet deadlines with careful attention to detail.
• Relevant education or certification such as a degree in healthcare administration, health information management, nursing, business, or a related field; coding or auditing credentials (e.g

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