Fraud Investigator

• Review and validate anomalies and prioritized leads from War Room analytics, including Provider 360, anomaly detection, and network analysis
• Develop cases for potential community care provider fraud, waste and abuse and coordinated billing schemes
• Build War Room referral packages supporting potential administrative actions, including provider removals, referral holds, recoupments, and oversight referrals
• Help produce weekly analytic runs and decision-ready case packages containing facts, analysis, recommendations, and traceability
• Prepare claim review workpapers and determination packages; apply case-file QA checklists and sampling plans
• Help design the end-to-end case workflow from intake to closure, including roles, handoffs, SLAs, and escalation paths aligned with CIRTS triage practices
• Contribute to intake and triage SOPs, case lifecycle and status taxonomy, and standard investigation templates
• Maintain overpayment, recovery, referral status, oversight, and tracking registers
• Provide investigative subject-matter input on fraud, waste and abuse typologies, rule logic, provider risk-scoring, and case-prioritization criteria
• Perform case documentation and evidence work only under active federal investigator direction; do not open cases, make findings, or make referral decisions
• Collaborate with OIC staff, VA OIG, and VHA stakeholders
• Support ad hoc white papers, outcome summaries, and leadership briefings
• Assist with training materials, kaizen sessions, after-action debriefs, and knowledge transfer so VA staff can operate the War Room independently by contract end

Senior Healthcare Fraud Investigator

• 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
• Handle multiple caseload assignments concurrently
• Organize and analyze complex evidentiary patterns
• Interview witnesses and others and obtain statements
• Complete complex investigative reports applying applicable regulations, rules, and laws
• Research relevant offenses and conduct investigations to detect or verify suspected violations
• Obtain information and evidence through observation, record examination, and interview
• Analyze investigation results and determine appropriate corrective steps
• Prepare correspondence and referral summary letters
• Maintain confidentiality of health privacy information
• Conduct site verifications to verify provider operational status
• Appear in court to testify about work findings when required
• Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters
• Report work activity in a timely manner
• Attend meetings, training, and conferences

Fraud Investigator – Medicare

• 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
• Work independently with minimal supervision and as part of teams with state and/or federal investigators
• Manage multiple caseload assignments concurrently
• Organize and analyze complex evidentiary patterns
• Interview witnesses and other individuals and obtain statements
• Prepare complex investigative reports applying program regulations, rules, and applicable federal or 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 and recommend appropriate actions
• Prepare correspondence and referral summary letters
• Maintain objectivity, accuracy, tact, and confidentiality when handling health privacy information
• Adapt investigation plans and respond effectively to unplanned situations
• Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters
• Manage and prioritize workload to meet or exceed customer metrics

• Perform high-level complex investigations of medical professional service providers
• Develop cases for law-enforcement referral, education, overpayment recovery, and other administrative actions
• Work with internal resources, external agencies, state and federal investigators, and other personnel
• Respond to requests for data and support
• Manage multiple concurrent caseload assignments
• Organize and analyze complex evidentiary patterns
• Interview witnesses and other involved parties and obtain statements
• Complete investigative reports applying relevant program regulations, rules, and laws
• Research relevant offenses and investigate alleged offenses to detect or verify suspected violations
• Obtain information and evidence through observation, record examination, and interviews
• Analyze investigation results and determine whether allegations are corroborated
• Determine appropriate corrective actions with stakeholders
• Prepare correspondence and referral summary letters
• Maintain objectivity, accuracy, tact, and confidentiality when handling health privacy information
• React to unplanned situations and adapt investigative plans
• Provide training and mentoring on investigative tools and skills
• Develop expertise in tools supporting investigations and identify potential fraud schemes
• Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters
• Attend meetings, training, and conferences; travel overnight as required
• Potentially testify in court regarding investigative findings

• Conduct detailed, data-driven research on suspicious activity using Castle, Amplitude, and Metabase
• Identify risk based on established playbooks
• Maintain rigorous investigative documentation and produce summaries supporting suspicious activity reporting and audit requirements
• Monitor real-time fraud queues and mitigate high-risk transactions within defined SLAs
• Partner with L2 Investigators and Team Leads to escalate complex cases and respond to emerging fraud trends
• Execute internal operating procedures and provide feedback on process gaps or system inefficiencies
• Apply subject matter expertise to daily investigations in alignment with fraud policies and regulatory requirements

• Lead complex fraud investigations involving multiple accounts, transactions, channels, and/or subjects
• Identify and analyze emerging fraud trends, typologies, and risk indicators
• Conduct root cause analysis of fraud events and identify opportunities to strengthen fraud controls
• Use internal systems, reporting, and available data sources to investigate linked activity and suspicious patterns
• Prepare clear, concise, and comprehensive case documentation, investigative summaries, and escalation materials
• Support high-priority escalations and complex fraud events requiring timely containment and coordination
• Partner with operations, compliance, legal, technology, and other stakeholders to support investigative outcomes
• Improve investigative procedures, documentation standards, and case management practices
• Provide subject matter expertise and guidance to business partners and team members
• Identify opportunities for process improvement and stronger fraud mitigation practices
• Protect, secure, and properly handle confidential Ascensus and client data

Senior Fraud Investigator

• 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
• Work independently with minimal supervision and direction
• Work with state and federal investigators and other personnel
• Handle multiple caseload assignments concurrently
• Organize and analyze complex evidentiary patterns
• Interview witnesses and other individuals and obtain statements
• Complete complex investigative reports applying program regulations, rules and applicable federal or 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
• Determine appropriate steps to address identified issues
• Prepare correspondence and communicate objectively, accurately and tactfully
• React to unplanned situations and adapt investigative plans
• Maintain confidentiality of health privacy information and comply with applicable laws, rules and regulations
• Provide training and mentoring on investigative tools and skills
• Develop expertise in tools supporting investigations and identify potential fraud schemes
• Attend meetings, training and conferences; travel overnight as required
• Potentially appear in court to testify about investigative findings

• 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
• Work independently with minimal supervision and direction
• Collaborate with state and federal investigators and other personnel
• Manage multiple caseload assignments concurrently
• Organize and analyze complex evidentiary patterns
• Interview witnesses and other individuals and obtain statements
• Complete complex investigative reports applying regulations, rules, and federal or state laws
• Research relevant offenses and conduct efficient 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
• Determine appropriate steps to address identified issues
• Prepare correspondence and communicate objectively, accurately and tactfully
• Maintain confidentiality of health privacy information and comply with applicable laws, rules and regulations
• Provide training and mentoring on investigative tools and skills
• Develop expertise in tools supporting investigations and identify potential fraud schemes
• Educate providers, provider associations, law enforcement, contractors and beneficiary advocacy groups on program safeguard matters
• Attend meetings, training and conferences; travel overnight as required
• Appear in court to testify to investigative findings when required

• Investigate potential scams and fraud involving OpenAI products, including complex or coordinated activity
• Document clear, defensible findings
• Assess urgent and ambiguous cases
• Distinguish substantiated abuse from legitimate use
• Recommend proportionate responses
• Communicate findings, uncertainty, and recommendations to leadership and cross-functional partners
• Work with colleagues across the company to improve responses to emerging scams and fraud

Abuse Investigator – Scams & Fraud

• Perform high-level complex investigations of medical professional service providers
• Develop cases for referral to law enforcement, provider 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
• Handle multiple caseload assignments concurrently
• Organize and analyze complex evidentiary patterns
• Interview and obtain statements from witnesses and others
• Complete complex investigative reports applying regulations, rules, and applicable federal or 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
• Determine appropriate steps with others to address identified issues
• Prepare objective and accurate correspondence
• Maintain confidentiality of health privacy information
• Appear in court to testify about work findings when required
• Educate providers, provider associations, law enforcement, contractors, and beneficiary advocacy groups on program safeguard matters
• Attend meetings, training, and conferences