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SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. The role conducts routine and focused provider and member audits and monitoring events, supports the coordination of external audits, and contributes to the Annual Program Integrity Workplan and the Medicare D-SNP Program Integrity framework.

YEAR

San Francisco Health Plan

Investigator, Program Integrity

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The Lead Special Investigations Unit Investigator works as an integral member of the Special Investigations Unit (SIU) performing as a Lead team member, providing oversight and guidance with provider training communications and documentation, fraud data analysis, data mining, non-fraud referrals, and the training of SIU team members. Completes investigation after referrals to law enforcement (Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) and Department of Justice (DOJ) or local police) and initiate process with L.A.

L.A. Care Health Plan

Lead Special Investigation Unit Investigator

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Must be currently certified and in good standing or obtain certification within twelve (12) months of hire with one of the following: Health Care Anti-Fraud Associate (HCAFA), Accredited Health Care Fraud Investigator (AHFI), Association of Certified Fraud Examiners (CFE), or National Health Care Anti-Fraud Association (NHCAA). Responds to Requests for Information (RFIs) from National Benefit Integrity MEDIC, U.S. Office of Personnel Management Office of the Inspector General (OPM OIG), State Departments of Insurance (DOI), and other law enforcement agencies, as appropriate.

Parkland Health

Clinical Special Investigations Unit Investigator- Health Plan

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Duties of this position include, but are not limited to: Investigates complaints filed by consumers against aforementioned licensed and unlicensed individuals, using interviewing skills and techniques, possesses a thorough knowledge of mechanical licensing practices, laws, regulations and documents, discusses complaints, prepares a thorough written report of findings, responds to telephone inquiries and manages an investigative case load. The main purpose of this position is to gather facts and to prepare investigative reports to aid in the resolution of complaints filed with the mechanical licensing boards by consumers against licensed and unlicensed plumbers, electricians, heating, ventilation, air-conditioning, and refrigeration contractors (HVACR), stationary engineers, elevator mechanics, and locksmiths.

State of Maryland

Mechanical Boards Investigator (LICENSING & REGULATION INVESTIGATOR II)

Coordinates with various internal customers (e.g., provider services, contracting and credentialing, healthcare services, member services, claims, etc.), to gather documentation pertinent to investigations. Responsible for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care, and recognizing and adhering to national and local coding and billing guidelines in order to maintain coding accuracy and excellence.

Molina Healthcare Inc

Investigator, Special Investigative Unit (Remote)

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear directions on what it takes to succeed in your role as well as provide development for other roles you may be interested in. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

UnitedHealth Group is a health care and well-being company that’s dedicated to improving the health outcomes of millions worldwide. We are comprised of two distinct and complementary businesses, UnitedHealthcare and Optum, working to build a better health system for all. Here, your contributions matter as they will help transform health care for years to come. Make an impact with a diverse team that shares your passion for helping others.

What we do

Gain insights on how we work to help people live healthier lives and help make the health system work better for everyone by watching this video.

<a href="https://www.youtube.com/watch?v=5PbNyi2IDkY">https://www.youtube.com/watch?v=5PbNyi2IDkY</a> 

Caring. Connecting. Growing together. 

Being a part of UnitedHealth Group means working to improve health outcomes for everyone, including yourself. Here is how:

• Caring. Your total health and well-being are important to us. Whatever matters most to you — we have resources to help you be your best at work and at home. The benefits range from free Peloton courses to financial counseling. <a href="https://careers.unitedhealthgroup.com/culture/what-we-offer/">Learn more about what we offer.</a> 

• Connecting. We recognize our collective power to make an impact across our communities because we believe the health of any society is measured by the overall health of its people. <a href="https://careers.unitedhealthgroup.com/culture/">Learn more about our culture.</a> 

• Growing together. UnitedHealth Group is full of inspiring career stories, and we offer a lifetime of opportunities. <a href="https://careers.unitedhealthgroup.com/career-areas/">Discover all the ways you can learn, grow and develop.</a>

UnitedHealth Group Inc.

Senior Investigator

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Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Investigator - New Mexico

We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes.

Senior Investigator - Rhode Island

Partners with internal departments (e.g., Claims, Medical Management, Legal, Provider Relations) to implement corrective actions such as provider education, prepayment review, payment suspension, and overpayment recovery; manages corrective action and repayment plans and processes claims in SIU pend queues. frame-loader#lazyLoad clinch:authenticated@document->frame-loader#reload" data-controller="frame-loader" data-src="/blocks/jobs/22dd666b9db20bcc871b61c3c4656ac0/favourites?page_id=307adbbfc8bd0f5a14f95c1c6bbc3490" id="22dd666b9db20bcc871b61c3c4656ac0_favourites">.

Boston Medical Center

Clinical Investigator II

Develop and maintain collaborative and liaison relationships with Blue Cross Blue Shield Association (BCBSA), Blue Cross Blue Shield (BCBS) Plans, HHS OIG, other carriers' anti-fraud professionals, law enforcement and regulatory agencies. May attend webinars and conferences like BCBSA, National Health Care Anti-Fraud Association (NHCAA), and Association of Certified Fraud Examiners (ACFE) to keep apprised of developments in health care fraud.

Premera Blue Cross

Investigator III

4+ years of experience as a Private Investigator, Private Detective, Licensed Investigator, Fraud Investigator, Insurance Investigator, or another closely related investigative role. Experience gathering, analyzing, and compiling information on legal, financial, or personal matters, including background checks, surveillance, interviews, and records research.

HOUR

Mercor

Private Investigator - AI Evaluation

Manatal

PART_TIME

You'll document findings through detailed reports, obtain written and recorded statements, conduct scene investigations, and capture photographic evidence such as accident scenes and vehicle damage. With a leadership team boasting over 25 years of field experience, we are committed to unlocking the potential of our employees and creating a supportive, tight-knit community.

Lemieux & Associates LLC

Licensed SIU Field Investigator

Talent Acquisition

Lemieux & Associates is seeking a part-time, on-call SIU Field Investigator in Albuquerque, NM, who is ready to put their investigative expertise to work in a rewarding role where every case presents a new challenge. With a leadership team boasting over 25 years of field experience, we are committed to unlocking the potential of our employees and creating a supportive, tight-knit community.

SIU Field Investigator

Lemieux & Associates is seeking a part-time, on-call Bilingual SIU Field Investigator in Stamford, CT, who is ready to put their investigative expertise to work in a rewarding role where every case presents a new challenge. With a leadership team boasting over 25 years of field experience, we are committed to unlocking the potential of our employees and creating a supportive, tight-knit community.

Bilingual SIU Field Investigator

Licensed Surveillance Field Investigator

Collaborates with internal business partners, compliance, legal, provider and payment integrity teams, and external agencies to coordinate investigative activities, support corrective actions, recoveries, and case resolution efforts. 2+ years Fraud, waste, and abuse investigations, healthcare investigations, claims audits, payment integrity, healthcare compliance, law enforcement investigations, or a related investigative field required.

Centene Corporation Group

SIU Investigator

CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. Job Summary: The Special Investigations Unit (SIU) III is responsible for investigating and resolving high complexity allegations of healthcare fraud, waste and abuse (FWA) by medical professional, facilities, and members.

CareSource

SIU Investigator III (Must live in Arkansas)

Parkland Hospital

At the Blue Cross and Blue Shield Association (BCBSA), we provide business strategy, technical support and consulting expertise to 36 Blue Cross and Blue Shield companies across the nation, employing more than 1,000 of the best strategic thinkers in the industry.  We are a Brand manager that sets quality control standards for the 36 independent companies that use the Blue Cross and Blue Shield Brands, and we serve as a trade association that represents these Blue companies. It is through our involvement that the Blues companies share a united vision and strategy while also benefiting from the local strength of all member companies.

Blue Cross and Blue Shield Association

Fraud Claims Law Specialist (FCLS) or Fraud Claims Law Associate (FCLA) designations and Certified Insurance Fraud Investigator (CIFI) or Certified Fraud Examiner (CFE) designations are preferred. Investigates files by using appropriate field, computer and telephone investigative techniques and provides appropriate documentation of actions in a thorough timely manner.

Fraud Investigator Jobs in the United States

Investigator, Program Integrity San Francisco Health Plan

Lead Special Investigation Unit Investigator L.A. Care Health Plan

Clinical Special Investigations Unit Investigator- Health Plan Parkland Health

Mechanical Boards Investigator (LICENSING & REGULATION INVESTIGATOR II) State of Maryland

Investigator, Special Investigative Unit (Remote) Molina Healthcare Inc

Senior Investigator UnitedHealth Group Inc.

Investigator - New Mexico UnitedHealth Group Inc.

Senior Investigator - Rhode Island UnitedHealth Group Inc.

Clinical Investigator II Boston Medical Center

Investigator III Premera Blue Cross

Private Investigator - AI Evaluation Mercor

Licensed SIU Field Investigator Lemieux & Associates LLC

SIU Field Investigator Lemieux & Associates LLC

Bilingual SIU Field Investigator Lemieux & Associates LLC

Licensed Surveillance Field Investigator Lemieux & Associates LLC

SIU Investigator Centene Corporation Group

SIU Investigator III (Must live in Arkansas) CareSource

Clinical Special Investigations Unit Investigator- Health Plan Parkland Hospital

Investigator III Blue Cross and Blue Shield Association

SIU Investigator Military, Veterans and Diverse Job Seekers

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