SIU Clinical Healthcare Fraud Investigator III (ATL)

The SIU Clinical Healthcare Fraud Investigator III leads complex, high impact investigations into fraud, waste, and abuse across multiple healthcare service lines. The Intersect Group partners with mission focused healthcare organizations dedicated to improving access, quality, and equity of care for large and diverse member populations.

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.