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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting complex fraud investigations, analyzing claims documentation, and developing proactive fraud prevention strategies. Proficient in collaborating with cross-functional teams and presenting findings to senior leadership.
Highest-signal resume keywords
Fraud InvestigationClaims Documentation ReviewAnalytical SkillsFraud Detection MethodologiesQuality Auditing
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims InvestigationFraud Prevention StrategiesMedical Record ReviewData AnalysisRisk-Scoring MethodologiesDocumentation of FindingsEvidence GatheringEscalation TriggersQuality Trend IdentificationFinancial Exposure Quantification
Soft Skills
Problem-SolvingWritten CommunicationVerbal CommunicationTraining and CoachingCollaboration
Industry Keywords
Supplemental HealthFraud IndicatorsComplianceRisk ManagementClaims OperationsAudit DocumentationLegal ProceedingsFraud Reporting RequirementsProcess GapsProvider Misconduct
About the role
Key responsibilities & impact- Lead complex investigations involving suspected fraud, abuse, provider misconduct, material misrepresentation and organized fraud schemes
- Conduct comprehensive reviews of claim files, supporting documentation, medical records, provider information and payment history
- Analyze claim activity to identify unusual patterns, trends and fraud indicators
- Develop and execute investigation plans based on risk, complexity and financial exposure
- Determine investigative actions and escalation paths
- Document investigative findings, recommendations and outcomes
- Conduct quality audits of staff-processed claims
- Identify quality trends, error patterns, process gaps and coaching opportunities
- Provide audit findings, feedback and recommendations to Claims Operations leaders
- Maintain audit documentation and reporting
- Partner with Claims Analytics and Data Science teams to develop fraud detection methodologies
- Prioritize investigation inventory using risk-scoring methodologies
- Quantify financial exposure and recoverable amounts
- Identify emerging fraud schemes and recommend mitigation strategies
- Coordinate medical record procurement and evidence gathering
- Validate submitted documentation against provider records
- Evaluate claim eligibility, diagnosis validity, treatment patterns and supporting evidence
- Partner with Legal, Compliance, Risk Management and SIU on compliant investigations
- Prepare investigation summaries and supporting materials for reviews
- Support regulatory inquiries, audits, legal proceedings and fraud reporting requirements
- Develop proactive fraud prevention strategies for Supplemental Health
- Recommend policy, workflow, automation and control enhancements
- Partner with Product, Operations and Technology leaders on fraud mitigation initiatives
- Train claims professionals to identify fraud indicators and escalation triggers
- Provide consultation and guidance on suspicious claims
- Develop investigation playbooks, reference materials and best practices
- Foster awareness of fraud risks across Claims Operations
Requirements
What you’ll need- Bachelor's degree or equivalent experience
- Strong analytical and problem-solving skills
- Experience reviewing medical records and claim documentation
- Ability to conduct complex investigations independently
- Strong written and verbal communication skills
- Experience presenting findings to senior leadership
- Experience with Supplemental Health fraud investigations
- Knowledge of fraud indicators and escalation triggers
- Knowledge of claims investigation, quality auditing, fraud detection and analytics
- Ability to review medical records, evidence and provider information
- Ability to work with Legal, Compliance, Risk Management and SIU
- Ability to develop fraud prevention strategies and investigation playbooks
Benefits
Comp & perks- Discretionary annual incentive award based on individual and business performance
- Generous vacation and sick time
- Paid family, parental and adoption leave
- Medical coverage
- Company-paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment
- Career growth support