SIU Investigator III

CareSource

. Develop, coordinate, and conduct strategic, fact-driven investigative projects .

Posted 10/10/2026full-timeRemote • United StatesMid-LevelSenior💰 $72,200 - $115,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare fraud investigations, including the application of medical standards and coding guidelines, while effectively managing investigative projects and collaborating with cross-functional teams. Proficient in data analysis and report generation, ensuring compliance with regulatory standards and maintaining confidentiality.

Highest-signal resume keywords

Healthcare Fraud InvestigationsAccredited Healthcare Fraud Investigator (AHFI)Data AnalysisMedical CodingRegulatory Compliance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalyticsMedical CodingReport GenerationInvestigative ResearchProject ManagementStatistical SamplingAuditingMedical TerminologyCPT CodesICD Codes

Soft Skills

Critical ThinkingInterpersonal SkillsProblem-SolvingAttention to DetailEffective Listening

Tools & Technologies

Microsoft OfficeRAT-STATS

Certifications & Qualifications

Accredited Healthcare Fraud Investigator (AHFI)Certified Fraud Examiner (CFE)

Industry Keywords

MedicaidMedicareHealthcare ComplianceFraud, Waste, and Abuse (FWA)Legal CounselCorrective Action Plans

About the role

Key responsibilities & impact

Develop, coordinate, and conduct strategic, fact-driven investigative projects
Review business processes, execute investigative activities, and develop investigation outcome recommendations
Manage the development, production, and validation of reports using claims, eligibility, pharmacy, and clinical data
Translate analytical findings into actionable items
Manage the strategic investigative plan and drive team investigative outcomes
Ensure quality outcomes through auditing and oversight
Prioritize, track, and report investigation status
Report identified corporate financial impact issues
Analyze complex provider claim submissions using coding guidelines
Research and interpret state-specific Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines
Apply medical standards and healthcare authoritative sources to investigative approaches
Collaborate with the data analytics team and use RAT-STATS for statistically valid random sampling
Coordinate and conduct on-site and desk audits of medical records and claims
Manage and make decisions on claims pended for investigative purposes
Prepare and conduct in-depth complex interviews
Execute and manage provider formal corrective action plans
Participate in meetings with operational departments, business partners, regulatory partners, and Legal General Counsel
Support legal actions, corrective actions, negotiations, recovery efforts, settlements, and litigation evidentiary documents
Present, support, and defend investigative research for formal corrective action approval
Maintain relationships with law enforcement agencies, task force members, SIU staff, and external fraud-investigation contacts
Develop and present internal and external formal presentations
Attend fraud, waste, and abuse training and conferences as needed
Support regulatory FWA reports to federal and state Medicare/Medicaid agencies
Manage sensitive confidential investigative information
Maintain compliance with laws, regulations, contracts, the CareSource Corporate Compliance Plan, and Anti-Fraud Plan
Assist with federal and state regulatory audits as needed

Requirements

What you’ll need

Must live in Georgia
Bachelor’s Degree or equivalent years of relevant work experience in a health-related field, law enforcement, or insurance required
Minimum of five (5) years of experience in healthcare fraud investigations, medical coding, pharmacy, medical research, auditing, data analytics, or related field required
One of the following certifications required: Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE)
Master’s Degree preferred
Intermediate proficiency in Microsoft Office, including Outlook, Word, Excel, Access, and PowerPoint
Effective listening and critical thinking skills; ability to identify gaps in logic
Strong interpersonal skills, professionalism, integrity, and ethics
Excellent problem-solving and decision-making skills with attention to detail
Background in research and drawing conclusions
Ability to perform intermediate data analysis and articulate understanding of findings
Ability to work under limited supervision with moderate latitude for initiative and independent judgment
Ability to manage a demanding investigative caseload
Ability to develop, prioritize, and accomplish goals
Strong writing skills and ability to compose detailed investigative reports and professional internal and external correspondence
Knowledge of Medicaid, Medicare, and healthcare rules preferred
Background in medical terminology, CPT, HCPCS, ICD codes, or medical billing preferred
Complex project management skills preferred
Occasional travel up to 10% may be required

Benefits

Comp & perks

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