Investigator

Integrity Management Services, Inc.

. Perform high-level complex Medicare and Medicaid investigations and develop cases for future action, including law enforcement referrals, education, overpayment recovery, and other administrative actions .

Posted 10/10/2026full-timeRemote • Virginia • United StatesMid-LevelSenior💰 $50,000 - $70,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting complex Medicare and Medicaid investigations, analyzing claims data for fraud detection, and preparing detailed investigative reports in compliance with federal and state regulations. Proficient in developing corrective actions and coordinating with law enforcement and healthcare agencies.

Highest-signal resume keywords

Investigative ExperienceData Analysis SkillsKnowledge of CMS Medicare Program Integrity ManualMedical Terminology ProficiencyCertified Fraud Examiner (CFE)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Investigative TechniquesData AnalysisFraud DetectionMedical ReviewClaims ReviewEvidence CollectionCase File DocumentationPolicy ResearchStatistical AnalysisHealthcare Coding

Soft Skills

Strong CommunicationTeam CoordinationMentoring SkillsDetail OrientationProblem Solving

Tools & Technologies

Case Tracking ToolsDatabase Management SystemsInternet Access

Certifications & Qualifications

Certified Fraud Examiner (CFE)Accredited Health Care Fraud Investigator (AHFI)

Industry Keywords

MedicareMedicaidHealthcare FraudBenefit IntegrityICD-9-CMICD-10-CMHCPCS Level IICPT CodesLaw Enforcement CoordinationAdministrative Actions

About the role

Key responsibilities & impact

Perform high-level complex Medicare and Medicaid investigations and develop cases for future action, including law enforcement referrals, education, overpayment recovery, and other administrative actions
Conduct investigations into alleged healthcare fraud, waste, and abuse by researching offenses, reviewing records, performing interviews, and collecting evidence
Analyze investigative findings to determine whether allegations are substantiated and develop corrective actions or referrals with colleagues and subject matter experts
Develop, document, and maintain comprehensive case files and update databases and case tracking tools
Research Medicare and Medicaid claims data and other information to establish policy requirements
Prepare detailed investigative reports applying federal or state laws, rules, and regulations
Coordinate with internal teams and external agencies, including law enforcement, legal counsel, CMS, and state or federal investigators
Conduct background research on suspect providers to identify adverse relationships, sanctions, exclusions, or disqualifying information
Review and interpret healthcare policies, regulations, and instructions
Ensure evidence is collected, documented, and safeguarded according to rules of evidence and investigative guidelines
Analyze claims data to identify fraud, waste, and abuse patterns or anomalies and contribute to fraud scheme detection methodologies
Respond to law enforcement and client requests for data, documentation, or investigative support
Review and approve administrative action requests before submission to CMS and provide training and mentoring
Maintain statistics on submitted administrative actions and maintain template documents
Conduct on-site visits and in-person interviews when required

Requirements

What you’ll need

Bachelor degree in business or related field with 5-7 years experience (e.g., law enforcement investigation, statistics, data analysis)
6+ years investigative experience in the Healthcare industry
At least 3 years of experience in benefit integrity investigation/detection or a related field demonstrating expertise in reviewing, analyzing/developing information, and making appropriate decisions
Knowledge of CMS Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions
Strong investigative skills
Advanced data analysis skills
Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes
Utilizes Medicaid and Contractor guidelines for coverage determinations
Experience reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases
Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI) preferred
Must pass post hire background screening checks
For remote work, required to have wired and/or wireless internet access
Ability to obtain security clearance, if required by Client/Contract

Benefits

Comp & perks

Vacation
Sick leave
Paid holidays
Health insurance
Dental insurance
Vision insurance
Short- and long-term disability
Life insurance
Employee assistance plan
401(K) retirement plan
Educational benefits
Remote work
Wired and/or wireless internet access required for remote work