SIU Clinical Healthcare Fraud Investigator III (ATL)

The Intersect Group

Los Angeles, CA(remote)

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JOB DETAILS

SALARY

$45–$55 Per Hour

SKILLS

Analysis Skills, Billing, C++ Active Template Libraries (ATL), Clinical Competency, Clinical Data, Clinical Medicine, Clinical Study Publications, Communication Skills, Community Support, Content Management Systems (CMS), Corrective Action, Current Procedural Terminology (CPT), Data Analysis, Documentation Review, Drug Development, Fraud Investigation, Healthcare, Healthcare Common Procedure Coding System (HCPCS), ICD-10, Investigative Reports, Legal, Managed Care, Mentoring, Multilingual, Nursing, Operations Management, Pharmacy, Power BI, Presentation/Verbal Skills, Process Improvement, Quality Management, Quality of Care, Regulations, Regulatory Compliance, Reimbursement, Reporting Skills, Spanish Language, Tableau, Trend Analysis, Writing Skills

LOCATION

Los Angeles, CA

POSTED

22 days ago

Special Investigation Unit Investigator III - Healthcare
Remote Opportunity West Coast Hours
Pay Rate: $45.00-55.00 per hour
Contract Opportunity 16 Weeks

Company Overview
The Intersect Group partners with mission focused healthcare organizations dedicated to improving access, quality, and equity of care for large and diverse member populations. Our client operates within a highly regulated environment and emphasizes integrity, compliance, and innovation to support vulnerable communities at scale. This is an opportunity to contribute to meaningful work while helping safeguard critical healthcare programs.

Role Summary
The SIU Clinical Healthcare Fraud Investigator III leads complex, high impact investigations into fraud, waste, and abuse across multiple healthcare service lines. This role owns the full investigation lifecycle and applies clinical expertise, data analysis, and regulatory knowledge to identify and resolve potential misconduct.

This position plays a key role in protecting organizational integrity by partnering with internal stakeholders and external agencies while mentoring team members and enhancing investigative standards.

Key Responsibilities
Lead end to end investigations into suspected fraud involving providers, members, and vendors
Review clinical documentation, claims data, and billing activity to identify irregular patterns and potential abuse
Conduct interviews, gather evidence, and maintain proper documentation and chain of custody
Analyze fraud schemes including upcoding, unbundling, billing anomalies, and credential misuse
Prepare detailed investigative reports and referral packages aligned with regulatory standards
Collaborate with compliance, legal, and external agencies to support enforcement and case resolution
Support recovery efforts by identifying overpayments and recommending corrective actions
Mentor junior investigators and contribute to process improvements and enhanced detection methods

Key Requirements
Minimum 3 years of healthcare fraud investigation experience managing complex cases through full lifecycle
Minimum 4 years of clinical experience such as nursing, pharmacy, or medical practice
Strong expertise in coding and reimbursement including CPT HCPCS and ICD 10
Deep knowledge of clinical documentation review, managed care operations, and regulatory compliance
Experience with healthcare program integrity regulations including CMS guidelines and federal requirements
Proficiency in data analysis tools such as Excel Power Query Tableau or Power BI
Strong analytical and investigative skills with the ability to interpret complex data and legal information
Excellent communication and report writing skills with the ability to present findings clearly

Preferred Qualifications
Professional certifications such as Certified Fraud Examiner or Accredited Healthcare Fraud Investigator
Experience within SIU or payment integrity functions
Active unrestricted clinical license aligned with professional background
Knowledge of emerging fraud trends and healthcare operational systems
Bilingual capabilities in Spanish or other commonly spoken languages

Call to Action
If you are a clinical professional with strong investigative expertise looking to make a measurable impact, The Intersect Group encourages you to apply today. Submit your resume and contact information for immediate consideration.

About the Company

The Intersect Group

The Intersect Group is a different and better business partner. We create unparalleled value for our clients by combining industry-leading Consulting capabilities with comprehensive Staffing and recruitment services. Clients trust us to deliver results based on our deep expertise and proven resources within finance, accounting, and information technology. Through our flexible delivery approach, you get the right solution, at the right time to accelerate your success and achieve all of your mission-critical objectives.

COMPANY SIZE

500 to 999 employees

INDUSTRY

Staffing/Employment Agencies

FOUNDED

2006