Investigator III
$80,200–$118,300 year
HybridMountlake Terrace, Washington, United States
Job Summary
Analyze healthcare claim data and vet referrals to detect fraudulent activity, then independently determine the most effective investigation method for each case. Conduct detailed field work including on-site visits, record collection, and surveillance while interviewing suspects and witnesses. Prepare cases for law enforcement depositions, participate in settlement negotiations, and perform root cause analysis to prevent future fraud. Collaborate with SIU colleagues and external agencies like BCBSA and HHS OIG to ensure compliance with regulatory requirements. Produce thorough, well-documented investigative reports subject to legal discovery and make recommendations for policy and process improvements. This hybrid role is based in Anchorage, Mountlake Terrace, or Spokane.
Required Qualifications
- Bachelor's degree in business administration, health care administration, finance, accounting, nursing or criminal justice
- 4 years of work experience in field of study
- 3 years of experience in fraud investigation, special investigation unit, or a related field
Desired Qualifications
- Certified Professional Coder (CPC), Certified Fraud Examiner (CFE), or Accredited Health Care Fraud Investigator (AHFI)
- 2 years of active experience in auditing and investigating in the healthcare industry
- Significant experience with relevant technology, such as background check systems, claims processing platforms, data mining, and fraud detection software
- Demonstrated knowledge of institutional and/or professional payment methodologies
- Strong understanding of health insurance reimbursement methodologies, including familiarity with International Classification of Diseases (ICD-10 CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
- Strong computer aptitude and experience with spreadsheet and database software, e.g., Excel, Access, Focus
- Demonstrated strong technical writing skills - ability to write reports and business correspondence and to prepare case files
- Ability to exercise a very high level of discretion when handling sensitive information
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