Investigator- Remote in Nebraska

About the position The Investigator is responsible for identifying, investigating, and preventing healthcare fraud, waste, and abuse (FWA). This role leverages claims data analysis, regulatory guidelines, and investigative methodologies to detect suspicious billing patterns and activities. The Investigator conducts thorough investigations, which may include fieldwork such as interviews and evidence collection, and ensures compliance with applicable regulatory requirements. If you reside in the state of Nebraska, you will have the flexibility to telecommute as you take on some tough challenges.

Responsibilities

• Assess and triage allegations of misconduct received within the organization
• Conduct investigations of low- to moderately complex fraud, waste, and abuse cases involving members, providers, employees, and third parties
• Identify potential fraudulent activities through data analysis, trend identification, and investigative techniques
• Develop and execute efficient, case-specific investigative strategies
• Maintain accurate, complete, and timely case documentation within the SIU case management system
• Gather, preserve, and analyze evidence; prepare clear and concise investigative summaries and reports
• Support settlement negotiations and provide documentation for legal or recovery actions
• Analyze referral data to identify patterns, trends, and emerging risks
• Ensure adherence to all applicable federal and state regulations, contractual obligations, and company policies
• Report suspected fraud, waste, and abuse to appropriate regulatory agencies as required
• Collaborate with internal teams and external partners, including state and federal agencies, as directed by SIU leadership
• Participate in regulatory meetings, workgroups, and cross-functional initiatives
• Communicate findings effectively through written reports and verbal presentations
• Establish and manage investigation goals, monitor progress, and adjust priorities as needed
• Participate in legal proceedings, including depositions, arbitration, and court testimony, as required

Requirements

• Bachelor’s degree or Associate’s Degree with 2+ years of equivalent work experience
• Ability to travel up to 25% as required
• Intermediate level of proficiency in Microsoft Excel and Word

Nice-to-haves

• Experience in healthcare fraud, waste, and abuse investigations or auditing
• Knowledge of federal and state healthcare regulations related to FWA
• Experience with data analysis and trend identification in healthcare claims
• Formal training in healthcare fraud investigations
• National Health Care Anti-Fraud Association (NHCAA) affiliation
• Accredited Health Care Fraud Investigator (AHFI)
• Certified Fraud Examiner (CFE)
• Certified Professional Coder (CPC)
• Medical Laboratory Technician (MLT)
• Knowledge of investigative techniques and evidence handling practices
• Strong analytical and problem-solving skills
• Ability to interpret complex data and identify irregular patterns
• Effective written and verbal communication skills
• Strong organizational skills with the ability to manage multiple investigations simultaneously

Benefits

• Paid Time Off which you start to accrue with your first pay period
• 8 Paid Holidays
• Medical Plan options
• Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance
• Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan
• Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

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