SIU Investigator III

CareSource

. Investigate and resolve high-complexity allegations of healthcare fraud, waste, and abuse involving medical professionals, facilities, and members .

Posted 10/28/2026full-timeRemote • United StatesMid-LevelSenior💰 $64,980 - $103,950 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare fraud investigations, medical coding, and data analytics, with a strong ability to analyze complex claims and translate findings into actionable outcomes. Proficient in managing investigative projects and maintaining compliance with healthcare regulations.

Highest-signal resume keywords

Healthcare Fraud InvestigationsMedical CodingData AnalyticsAccredited Healthcare Fraud Investigator (AHFI)Certified Fraud Examiner (CFE)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Data AnalysisMedical TerminologyCPT CodingHCPCS CodingICD CodingInvestigative ReportingProject ManagementStatistical SamplingClaims AuditingCorrective Action Plans

Soft Skills

Effective ListeningCritical ThinkingInterpersonal SkillsProblem-SolvingAttention to Detail

Tools & Technologies

Microsoft OfficeRAT-STATS

Certifications & Qualifications

Accredited Healthcare Fraud Investigator (AHFI)Certified Fraud Examiner (CFE)Certified Professional Coder (CPC)

Industry Keywords

MedicaidMedicareHealthcare RegulationsFraud, Waste, and Abuse (FWA)Corporate Compliance PlanAnti-Fraud Plan

About the role

Key responsibilities & impact

Investigate and resolve high-complexity allegations of healthcare fraud, waste, and abuse involving medical professionals, facilities, and members
Research, gather, and analyze data to identify trends, patterns, aberrancies, and outliers in provider billing behavior
Serve as a subject matter expert for other investigators
Develop, coordinate, and conduct strategic fact-driven investigative projects
Manage development, production, and validation of reports using claims, eligibility, pharmacy, and clinical data
Translate analytical findings into actionable items and drive investigative outcomes
Audit and oversee investigative team quality outcomes
Prioritize, track, and report investigation status
Report identified corporate financial impact issues
Analyze complex provider claim submissions using coding guidelines
Interpret state Medicaid, federal Medicare, and ACA/Exchange laws, rules, and guidelines
Apply medical standards and healthcare authoritative sources to investigative approaches
Collaborate with data analytics teams and use RAT-STATS for statistically valid random sampling
Conduct on-site and desk audits of medical records and claims
Manage and decide claims pended for investigative purposes
Conduct in-depth complex interviews
Execute and manage provider formal corrective action plans
Meet with operational departments, business partners, regulatory partners, and Legal General Counsel to develop cases and pursue legal actions, corrective actions, negotiations, recoveries, settlements, and litigation documents
Present, support, and defend investigative research for formal corrective actions
Maintain relationships with law enforcement agencies, task force members, SIU staff, and external fraud-investigation contacts
Serve as subject matter expert in the designated market and apply external intelligence to case analysis and development
Develop and present internal and external formal presentations
Attend fraud, waste, and abuse training and conferences
Support regulatory FWA reports to federal and state Medicare/Medicaid agencies
Manage sensitive confidential investigative information
Maintain compliance with laws, regulations, contracts, Corporate Compliance Plan, and Anti-Fraud Plan
Assist with federal and state regulatory audits
Perform other job-related instructions as requested

Requirements

What you’ll need

Must live in Arkansas
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)
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 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 correspondence
Presentation experience beneficial
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
Leadership qualities
Certified Professional Coder (CPC) preferred
NHCAA or other fraud and abuse investigation training 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