Lead Investigator

CareSource

. Serve as the face of the Special Investigations Unit with external federal and state regulatory agencies .

Posted 11/11/2026full-timeRemote • Georgia • United StatesSenior💰 $83,000 - $132,800 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Healthcare Fraud Investigations, utilizing advanced data analytics and statistical techniques to identify and mitigate fraud, waste, and abuse. Proficient in regulatory compliance and relationship management with federal and state agencies.

Highest-signal resume keywords

Healthcare Fraud InvestigationsData AnalyticsRegulatory ComplianceAccredited Healthcare Fraud Investigator (AHFI)Certified Fraud Examiner (CFE)

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Data AnalysisSASSQLInferential StatisticsDescriptive StatisticsInpatient Coding StandardsOutpatient Coding StandardsBilling Rules and RegulationsCPT CodesICD-10 Codes

Soft Skills

Critical ThinkingDecision-MakingProblem-SolvingVerbal CommunicationWritten Communication

Tools & Technologies

Microsoft ExcelMicrosoft AccessMicrosoft WordMicrosoft PowerPointRAT-STATS

Certifications & Qualifications

Certified Professional Coder (CPC)Master's Degree

Industry Keywords

MedicaidMedicareManaged Care PlansFraud DetectionCorporate Compliance Plan

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Serve as the face of the Special Investigations Unit with external federal and state regulatory agencies
Manage regulatory communications and ensure timely oversight-agency responses
Identify and monitor emerging fraud, waste, and abuse trends
Research claims, industry sources, and internal and external data to identify potential fraud
Use data analytics platforms to mine large data volumes and identify fraudulent activity, patterns, and billing anomalies
Develop and monitor the Annual Program Integrity Fraud, Waste and Abuse Plan
Develop and implement innovative best practices aligned with growth and regulatory oversight
Act as Program Integrity liaison with state and federal agencies
Support deployment and monitoring of state-specific regulations for Medicaid and Medicare programs
Build relationships through external fraud associations and industry partnerships
Identify cost-avoidance opportunities through prepayment review, provider education, and preventive measures
Ensure accuracy of regulatory reporting and respond to regulatory inquiries
Ensure high-volume, quality FWA referrals to state partners
Lead investigation on-sites and mentor the team
Conduct and assist with complex investigations
Collaborate with data analytics teams and use RAT-STATS for statistically valid random sampling
Manage investigation turnaround times and case documentation quality
Generate and trend fraud-detection leads to identify quality-improvement and focused-investigation opportunities
Identify trends and patterns using corporate processes, tools, reports, databases, policies, coding guidelines, and regulations
Manage and make decisions on claims pended for investigation
Maintain knowledge of state and federal laws, rules, and provider billing guidelines
Prepare and conduct in-depth complex interviews
Execute and manage provider corrective action plans
Participate in meetings with operational, business, legal, and regulatory partners
Support legal actions, corrective actions, negotiations, recoveries, settlements, and evidentiary-document preparation
Design data-analysis strategies for quality improvement and focused investigations
Monitor media and state and federal press releases for emerging schemes and exposure
Lead information-sharing activities and produce actionable data analyses
Manage confidential investigative information
Maintain compliance with laws, regulations, contracts, the Corporate Compliance Plan, and Anti-Fraud Plan
Assist with federal and state regulatory audits
Perform other job-related duties as requested

Requirements

What you’ll need

Bachelor’s Degree or equivalent years of relevant work experience in Fraud & Abuse Investigations required
Minimum of 10 years of experience in Healthcare Fraud, Healthcare data analysis, or Compliance required
Two of the following required: Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), or Certified Professional Coder (CPC), or 6 years of coding experience
Proven analytic skills in solving multi-dimensional problems
Advanced Microsoft Applications experience, including Excel, Access, Word, and PowerPoint
SAS and SQL skills and experience for analytics projects preferred
OIG/FBI/MFCU knowledge and experience
Knowledge of inferential statistics
Working knowledge of descriptive statistical applications and techniques
Critical listening, thinking, verbal, and written communication skills
Decision-making and problem-solving skills
Ability to work independently and within a team environment
Knowledge of multiple Medicaid, Medicare, and managed care plans
Strong knowledge of inpatient and outpatient coding standards, billing rules and regulations, and procedure and diagnosis codes including CPT, ICD-10, HCPCS, APC, and DRGs
Knowledge of value-based reimbursement methodology
Ability to lead analytic efforts
Master’s Degree preferred
Previous law enforcement experience preferred

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Comprehensive total rewards package
Occasional travel to meetings, training, and conferences