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Fraud Investigations Director Jobs (NOW HIRING)

State of Maine

Fraud Investigator

Portland, ME · On-site

$22.91 - $31.97/hr

Conduct fraud investigations. * Gather evidence. * Write investigation reports. * Refer cases for ... For additional information about this position please contact Tom Roth, Director of Fraud ...

City of Alexandria

Fraud Investigator I

Courtland, VA · On-site

Upon recommendation by the supervisor, approval by the director, and successful completion of the training program, the employee shall be redefined to a full-performance Fraud Investigator II becomes ...

New

Amoco Federal Credit Union

... investigations. * Review and assess data to confirm or disprove fraud claims or charge-offs ... In-depth dialogue, conversations and explanationswith customers, direct and indirect reports and ...

Bank OZK

SVP, Investigations and Recovery

Dallas, TX · On-site

Leads the Fraud Investigations and Recovery function of the Bank, holding overall accountability ... Performs or assigns other tasks as directed by management. Knowledge, Skills & Abilities

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Infographic showing various Fraud Investigations Director job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 85% Full Time, 12% Part Time, and 2% Contract. Highlights an 90% Physical, 3% Hybrid, and 7% Remote job distribution.

Fraud Investigator II

Westborough, MA • On-site

University of Massachusetts Medical School
Education • 10K+ employees
Learn more about University of Massachusetts Medical Schoolexternal

$78K - $88K/yr

Full-time

Posted 26 days ago

Key responsibilities

  • Conduct independent data mining and data analysis to detect aberrancies and outliers in claims data.

  • Develop reports of investigative findings, compile case file documentation, and calculate overpayments.

  • Communicate with providers regarding audit findings, recoveries, and educational feedback.

Job description

Overview
GENERAL SUMMARY OF POSITION:
Under the general direction of the Associate Director, or designee, the Fraud Investigator II serves a crucial role in combating fraud, waste and abuse ("FWA") within the Medicaid program. Investigations involve extensive research to identify industry trends and patterns which target aberrant billing practices. The Investigator II collaborates with the Associate Director on more complex case reviews as needed, in addition to performing activities related to data mining, data analysis and recoveries. With increasing independence, the Investigator II is assigned to multiple provider types and serves as a senior investigator in the Unit., The Investigator II will coach other investigators on developing techniques to find provider schemes based on federal and state regulations that govern Medicaid.
Responsibilities
MAJOR RESPONSIBILITIES:
  • Consistently apply in-depth knowledge of federal and state regulations and healthcare industry standards.
  • Conduct independent data mining and data analysis techniques utilizing claims data to detect aberrancies and outliers in claims and develop trends and patterns for potential cases.
  • Develop algorithms, queries, and reports to detect potential FWA activity.
  • Analyze member records and claims data to ensure compliance with applicable regulations, contracts and policy manuals.
  • Develop reports of investigative findings, compile case file documentation, calculate overpayments, and issue findings in accordance with agency policies and procedures.
  • Document work performed and audit results based on pre-determine standards and guidelines.
  • Communicate with providers routinely regarding issues including audit findings, recoveries and educational feedback.
  • Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance, based on findings.
  • Determine compliance with applicable Medicaid regulations by examining records
  • Assist investigator I staff with recognizing and identifying fraudulent patterns for increasingly complex cases.
  • Serve as a resource for departments to research and resolve integrity inquiries.
  • Update appropriate internal management staff regularly on progress of investigations and make recommendations for further initiatives such as new algorithms.
  • Create, maintain and manage cases within the tracking system to ensure information is accurate and timely.
  • Perform other duties as needed.

Qualifications
REQUIRED QUALIFICATIONS:
  • A Bachelors' degree in Business administration, finance, public health or related field; or equivalent years of experience.
  • 5-7 years of related experience in fraud examination, healthcare, business, finance or related field; with at least 2 years of experience conducting data mining in the healthcare insurance industry and claims related experience.
  • Knowledge of coding, reimbursement and claims processing policies.
  • Knowledge of the principles and practices of medical auditing.
  • Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions.
  • Knowledge of the law and regulations as it relates to fraud and fraud investigations.
  • Must have a track record of producing high quality work that demonstrates attention to detail.
  • Ability to multi-task, establish priorities and work independently to achieve objectives.
  • Ability to function effectively under pressure.
  • Proficient in Microsoft Office applications (Word, Excel, PowerPoint and Access)
  • Excellent Customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments.
  • Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor.
  • Strong oral and written communication skills including internal and external presentations.

PREFERRED QUALIFICATIONS:
  • Prefer individual possessing any of the following certifications or licensure: CPC or CPMA.
  • Advanced SQL and Microsoft Excel software skills.
  • Knowledge of State and federal regulations as they apply to public assistance programs
  • Strong Decision making skills with the ability to investigate and weigh alternatives and select the appropriate course of action.
  • Creative thinking skills with the ability to ask the needed "bigger- picture" questions that lead to process and team improvements.

Additional Information
Position requires travel to office in Westborough an average of two times per month.

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