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Posted: 10/20/2026Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates strong investigative skills and knowledge of Medicare and Medicaid programs, with the ability to analyze complex evidentiary patterns and communicate findings effectively. Capable of managing multiple caseloads while maintaining confidentiality and compliance with applicable laws and regulations.
Highest-signal resume keywords
Investigative SkillsKnowledge Of Medicare And MedicaidHealthcare Industry ExperienceCommunication SkillsCase Management
Tech Stack
Tools & technologiesAbout the role
Key responsibilities & impact- Perform high-level, complex investigations of medical professional service providers
- Develop cases for referral to law enforcement, education, overpayment recovery and other administrative actions
- Work with internal resources and external agencies to develop cases and corrective actions
- Respond to requests for data and support
- Manage multiple caseload assignments concurrently
- Organize and analyze complex evidentiary patterns
- Interview witnesses and other individuals and obtain statements
- Complete investigative reports applying regulations, rules, federal laws and state laws
- Research relevant offenses and conduct investigations to detect or verify suspected violations
- Obtain information and evidence through observation, record examination and interviews
- Analyze investigation results to determine whether allegations are corroborated
- Collaborate with others to determine appropriate corrective steps
- Prepare objective and accurate correspondence and communicate tactfully
- React to unplanned situations and adapt investigative plans and courses of action
- Maintain confidentiality of health privacy information and comply with applicable privacy laws, rules and regulations
- Educate providers, provider associations, law enforcement, contractors and beneficiary advocacy groups on program safeguard matters
- Potentially appear in court to testify about investigative findings
Requirements
What you’ll need- 2 years with BS/BA or 6 years of experience with a high school diploma/equivalent
- Knowledge of Medicare and/or Medicaid programs and their rules, regulations, policies and procedures
- Knowledge and experience in the healthcare industry
- Strong investigative skills
- Strong communication and organization skills
- Strong PC knowledge and skills
- US citizenship required
- Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases (preferred)
- Knowledge of investigative practices regarding healthcare providers (preferred)
- Background in evaluating, reviewing and analyzing medical claims and records (preferred)
- Ability to learn and operate a variety of data systems, equipment and tools used in investigations
- Ability to perform research and draw conclusions
- Ability to organize a case file and accurately document all steps taken
- Ability to present issues of concern and cite regulatory violations or alleged schemes
- Ability to compose correspondence, reports and referral summary letters
- Ability to communicate effectively internally and externally
- Ability to interpret laws and regulations
- Ability to handle confidential material
- Ability to manage and prioritize workload effectively
- Ability to educate providers, provider associations, law enforcement, contractors and beneficiary advocacy groups on program safeguard matters
- Ability to work independently and as part of a team
- Ability to attend meetings, training and conferences; overnight travel required
- May be required to appear in court and testify about work findings
Benefits
Comp & perks- Telework available from eligible locations
- Overtime may be available
- Shift differential may be available
- Discretionary bonus may be available
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Investigative ReportingData AnalysisMedical ReviewRegulatory InterpretationClaims ReviewEvidence CollectionResearch SkillsDocumentationFraud Case DevelopmentEvidentiary Pattern Analysis
Soft Skills
Organizational SkillsEffective CommunicationAdaptabilityTeam CollaborationConfidentiality Management
Tools & Technologies
Data SystemsInvestigation ToolsPC Skills
Industry Keywords
Healthcare ComplianceFraud InvestigationProgram Safeguard EducationFederal LawsState Laws