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Posted: 10/12/2026Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in investigating healthcare fraud, analyzing claims data, and developing policies to prevent financial loss. Proficient in advanced Excel for data analysis and familiar with CPT coding and fraud certifications.
Highest-signal resume keywords
Healthcare Fraud InvestigationAdvanced Excel ProficiencyCPT Coding FamiliarityFraud Certification (CFE, AHFI, AAPC)Investigative Experience
About the role
Key responsibilities & impact- Identify, investigate and develop cases against perpetrators of healthcare fraud
- Recover corporate and client funds paid on fraudulent claims
- Review claims for appropriate coding, data mining, entity review and law enforcement referral
- Use proprietary data and claim systems to review facility, professional and pharmacy claims
- Identify and develop enterprise-wide healthcare investigations that may impact multiple health plans, lines of business and/or states
- Establish rapport and ongoing working relationships with law enforcement
- Interface internally with senior-level management and the legal department throughout the investigative process
- Assist in training internal and external entities
- Assist in developing policies and procedures to prevent loss of company assets
Requirements
What you’ll need- Requires a BA/BS and minimum of 3 years related experience; or any combination of education and experience, which would provide an equivalent background
- Advanced Excel proficiency; ability to run pivot tables and analyze large datasets
- Familiarity with CPT coding
- Fraud certification from CFE, AHFI, AAPC or coding certificates preferred
- Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred
- Investigative experience preferred (e.g. health insurance, law enforcement)
- Candidates must be within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law
- New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless they provide an acceptable explanation
Benefits
Comp & perks- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) + match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual full-time work arrangement, except for required in-person training sessions
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Data AnalysisClaims ReviewData MiningEntity ReviewPolicy DevelopmentFraud DetectionNegotiation SkillsFinancial RecoveryCoding ComplianceInvestigative Techniques
Soft Skills
Relationship BuildingTraining AbilityCommunication SkillsCollaborationProblem Solving
Tools & Technologies
Proprietary Data SystemsClaims SystemsExcel Pivot Tables
Certifications & Qualifications
CFEAHFIAAPC
Industry Keywords
Healthcare FraudBenefit Programs ManagementLaw Enforcement CollaborationCorporate Asset ProtectionFraudulent Claims