Healthcare Fraud Investigator -SIU at Allied… · Albuquerq…

Overview

Company Overview:

Advance Your Career in Insurance Claims with Allied Universal® Compliance and Investigation Services. Allied Universal® Compliance and Investigation Services is the premier destination for a career in insurance claim investigation. As a global leader, we provide dynamic opportunities for claim investigators, SIU investigators, and surveillance investigators. Our team is committed to innovation and excellence, making a significant impact in the insurance industry. If you’re ready to grow with the best, explore a career with us and make a difference.

Job Description

Allied Universal® is hiring a Healthcare Fraud Investigator -SIU. The Healthcare Fraud Investigator is a learned professional role requiring advanced, specialized knowledge of healthcare fraud laws, reimbursement systems, and investigative methodologies customarily acquired through prolonged academic instruction and extensive professional experience. The Healthcare Fraud Investigator independently applies professional judgment, discretion, and analytical expertise to evaluate complex factual and legal issues, conduct non-routine investigative work, and render professional conclusions regarding suspected healthcare fraud, waste, abuse, and regulatory non-compliance involving federal and state healthcare programs. Some travel may be required for professional investigative activities, interviews, or continuing education.

RESPONSIBILITIES:

• Independently design and execute complex healthcare fraud investigations requiring professional judgment, specialized knowledge, and analytical interpretation rather than standardized or routine procedures
• Apply advanced understanding of healthcare fraud and abuse laws, including the False Claims Act, Anti-Kickback Statute, Stark Law, Civil Monetary Penalties Law, and CMS Medicare and Medicaid regulations, to evaluate conduct and assess liability exposure
• Perform sophisticated analysis of claims data, medical records, coding and billing practices, financial relationships, and utilization patterns to identify indicia of fraud or abuse
• Evaluate medical necessity, documentation sufficiency, and reimbursement appropriateness based on regulatory, clinical, and reimbursement standards
• Conduct investigatory interviews using professional investigative techniques, exercising discretion in assessing credibility, intent, and evidentiary weight
• Formulate professional investigative findings and conclusions based on complex factual records, regulatory interpretation, and expert judgment
• Prepare formal written investigative reports reflecting professional opinions, risk assessments, and compliance conclusions for senior leadership, legal counsel, and governing bodies
• Advise compliance leadership and legal counsel on investigative outcomes, fraud risk mitigation strategies, and remediation considerations using professional expertise
• Identify emerging fraud schemes and trends through continued professional study, interpretation of enforcement guidance, and application of investigative expertise
• Maintain professional independence, confidentiality, and adherence to ethical standards governing investigative and compliance professions

QUALIFICATIONS (MUST HAVE):

• Bachelor’s degree in criminal justice, healthcare administration, accounting, finance, public health, forensic studies, or a related discipline involving prolonged, specialized academic study
• Minimum of three (3) years of professional level investigative experience involving healthcare fraud, complex compliance investigations, regulatory enforcement, or government program integrity
• Demonstrated ability to exercise independent professional judgment in analyzing ambiguous facts, interpreting regulations, and drawing expert conclusions
• Professional experience in performing high-level analytical research and evaluative skills
• Proficiency in Fraud, Waste and Abuse (FWA) data analysis tools and software commensurate with experience
• Proficiency in Microsoft Office
• Ability to remain highly productive, strong attention to detail, with strong organizational skills
• Effective oral and written communication skills
• Demonstrated ability to manage sensitive information with integrity and discretion

PREFERRED QUALIFICATIONS (NICE TO HAVE):

• Master’s Degree in criminal justice, healthcare administration, accounting, finance, public health, forensic studies, or a related discipline involving prolonged, specialized academic study, Juris Doctor, or equivalent or advanced academic credential
• Demonstrated working Knowledge of Managed Care and the Medicaid and Medicare programs
• Professional certifications demonstrating specialized expertise, such as Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), Certified Internal Auditor (CIA), Accredited Healthcare Fraud Investigator (AHFI) or healthcare coding certifications (CPC, CPMA, etc.)
• Prior service with healthcare regulatory or enforcement agencies or in senior-level compliance investigation roles (retired or former OIG or MFCU experience)

BENEFITS:

• Medical, dental, vision, basic life, AD&D, retirement plan and disability insurance
• Seven paid holidays annually, sick days available where required by law
• Vacation time offered at an initial accrual rate of 3.08 hours biweekly; unused vacation is only paid out where required by law

Closing

Allied Universal® is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race/ethnicity, age, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, disability, protected veteran status or relationship/association with a protected veteran, or any other basis or characteristic protected by law. For more information: www.aus.com

If you have difficulty using the online system and require an alternate method to apply or require an accommodation, please contact our local Human Resources department. To find an office near you, please visit: www.aus.com/offices.

Requisition ID

2026-1616687