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Fraud Nurse Investigator Jobs (NOW HIRING)

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Provider Fraud Investigator

Lincoln, NE · On-site

$25.61/hr

JR2026-00028695 Provider Fraud Investigator (Evergreen) (Open) Applications No Longer Accepted On ... nursing, business or public administration, management, program analysis or evaluation of data ...

Highmark Health

Investigator

New York, NY

JOB SUMMARY This job is responsible for developing and maintaining an anti-fraud program which ... Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field ...

Highmark Health

Investigator

JOB SUMMARY This job is responsible for developing and maintaining an anti-fraud program which ... Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field ...

Highmark Health

Investigator

Pittsburgh, PA · On-site

JOB SUMMARY This job is responsible for developing and maintaining an anti-fraud program which ... Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field ...

Highmark Health

Investigator

Pittsburgh, PA · On-site

JOB SUMMARY This job is responsible for developing and maintaining an anti-fraud program which ... Bachelor's Degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field ...

Highmark Health

Lead Investigator

Pittsburgh, PA · On-site

$95K - $112K/yr

JOB SUMMARY This job is responsible for developing and maintaining an anti-fraud program which ... Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field ...

Highmark Health

Lead Investigator

Pittsburgh, PA

$95K - $112K/yr

JOB SUMMARY This job is responsible for developing and maintaining an anti-fraud program which ... Bachelor's degree in Accounting, Finance, Business Administration, Nursing, IT or Related Field ...

Parkland Health

The Clinical SIU Investigator ensures PCHP's accountability for compliance by overseeing, follow-up ... Licensed Vocational Nurse (LVN) with four years of Medicaid or CHIP Fraud, Waste, and Abuse ...

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How much do fraud nurse investigator jobs pay per hour?

As of Sep 2, 2026, the average hourly pay for fraud nurse investigator in the United States is $30.83, according to ZipRecruiter salary data. Most workers in this role earn between $22.12 and $35.34 per hour, depending on experience, location, and employer.

What is a fraud nurse investigator?

A Fraud Nurse Investigator is a registered nurse who examines medical claims for signs of fraud, waste, or abuse. They analyze patient records, billing practices, and provider documentation to ensure compliance with healthcare regulations. Their role helps prevent fraudulent activity, protect insurance companies from financial losses, and ensure patients receive appropriate care. Fraud Nurse Investigators typically work for insurance companies, government agencies, or healthcare organizations. Strong analytical skills, clinical knowledge, and attention to detail are essential for success in this role.

What are the typical daily responsibilities of a fraud nurse investigator?

A Fraud Nurse Investigator typically spends their day reviewing medical records and insurance claims to identify inconsistencies, communicating with healthcare providers, and documenting findings as part of ongoing investigations. They often collaborate with insurance companies, legal teams, and regulatory agencies to support fraud detection and prevention efforts. The role may also involve interviewing patients or witnesses, providing expert opinions on clinical matters, and participating in training sessions to stay current on industry trends. This multifaceted position offers a mix of independent case review and teamwork, making it both challenging and intellectually rewarding for those with a passion for detail and integrity.

What are the key skills and qualifications needed to thrive in the fraud nurse investigator position, and why are they important?

To excel as a Fraud Nurse Investigator, you need a strong background in nursing, analytical skills for reviewing medical claims, and knowledge of healthcare regulations, often supported by an RN license and clinical experience. Familiarity with fraud detection software, medical coding systems like ICD-10, and case management platforms is highly beneficial. Excellent communication, critical thinking, and attention to detail set top performers apart in this field. These skills and qualifications are vital for accurately identifying fraudulent activities, collaborating with investigative teams, and safeguarding healthcare resources.

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Fraud Nurse Investigator jobs near you
Infographic showing various Fraud Nurse Investigator job openings in the United States as of August 2026, with employment types broken down into 4% As Needed, 58% Full Time, 15% Part Time, and 23% Contract. Highlights an 99% Physical, and 1% Remote job distribution, with an average salary of $64,132 per year, or $30.8 per hour.

Nurse Investigator

The Health Plan of West Virginia Inc

Charleston, WV • On-site

Full-time

Posted 12 days ago

Job description

The Nurse Investigator works as part of the Special Investigations Unit (SIU) team, detecting and investigating suspected fraud, waste, and abuse (FWA). This position is responsible for conducting both pre-payment and post-payment reviews to ensure program integrity, and to support fraud, waste, and abuse detection and investigation efforts. This position serves as the SIU’s subject matter expert in terms of clinical reviews, coding and documentation, conducting medical chart reviews and billing audits. The successful candidate will utilize their unique blend of coding, claims payment, clinical, and payment integrity/investigations expertise to assist the SIU in achieving its mission to prevent, detect, investigate, and resolve healthcare fraud, waste, and abuse.

Required:

  1. Registered Nurse;
  2. Certified Coder (or eligible within 12 months)or similar certification;
  3. Basic knowledge of ICD-9/10, CPT, HCPCS, DRG and/or Rev codes;
  4. Proficiency with Office products, including Word and Excel;
  5. Critical problem-solving skills and attention to detail.

Desired:

  1. Healthcare investigations, program integrity, or similar experience;
  2. 3 years Medical Claims or multi-discipline clinical experience;
  3. Regulatory experience relevant to healthcare;
  4. Experience with WV Medicaid, Medicare Advantage, and/or Fully-Funded Commercial Health Insurance;
  5. Familiarity with CMS regulations.

Responsibilities:

  • Conducting full investigations which may include data analysis, research, contract review, medical records review, interviews of patients/witnesses/providers, site visits, consulting with other subject matter experts, coordination with law enforcement or regulatory agencies, and other necessary investigative activities;
  • Analyzing and synthesizing information from multiple sources including claims data, contracts, enrollment data, provider manuals, educational materials, bulletins, medical records, employee records, and state and federal regulations, to determine impact on claims payments as it relates to SIU cases or leads;
  • Creating plans of investigation, determining scope, timing, and direction of investigation;
  • Ensuring investigations are completed in a lawful, ethical, and appropriate manner;
  • Properly documenting all investigative actions and decisions in the case management/tracking system;
  • Ensuring all investigative actions and decisions are executed expeditiously, with integrity and discretion;
  • Serve as a subject matter expert for medical reviews, coding, and documentation;
  • Review and analyze healthcare claims, medical records, physician statements, care management reports, and other documentation which requires interpretation and understanding of state and federal regulations, standards of care, applicable benefit language, and reimbursement language to determine medical necessity, billing appropriateness, and sufficiency of documentation in the evaluation of cases for potential fraud, waste, or abuse;
  • Investigate, analyze, and render opinions on the delivery and billing of health care services
  • Conduct audits of medical charts and claims records;
  • Utilize knowledge of healthcare coding, medical policies, and other relevant guidelines to assess claims submissions and make appropriate recommendations to the SIU, claims examiners, and other relevant stakeholders;
  • Prepare findings identifying overpayments and/or inappropriate billing, documenting findings in a Word document, and overpayment calculations in a spreadsheet;
  • Prepare case reports for submission to regulatory and/or investigative agencies;
  • Speak and act confidently when conveying information, including explaining overpayment determinations which may include court testimony;
  • Coordinate with internal partners including Operations, Compliance, QI, Credentialing, and Provider Delivery Services to gather information relevant to the investigation;
  • Maintain licensure and certification, completing required continuing education.




8:00am to 5:00pm
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