Healthcare Fraud Investigator Resume Samples

Working for the healthcare industry, the Healthcare Fraud Investigator takes the main duty of detecting and investigating instances of fraud, waste, and abuse-related issues within the healthcare facility. Major duties associated with the role are mentioned on the Healthcare Fraud Investigator Resume as – analyzing medical claims and financial records; identifying irregularities and potentially fraudulent activities; working closely with law enforcement agencies, insurance companies, and healthcare organizations; gathering evidence, and conducting interviews, and framing cases against the healthcare unit that committed healthcare fraud.

The most sought-after skills include – strong analytical skills, knowledge of healthcare regulations, attention to detail, strong communication skills, the ability to collaborate with diverse stakeholders, including legal professionals; staying updated on industry regulations, and healthcare billing procedures; and fraud techniques. Possessing a bachelor’s degree in criminal justice, or healthcare administration is mandatory. However, a background in healthcare, finance, or law enforcement is commonplace among many job applicants.

Healthcare Fraud Investigator Resume example

Healthcare Fraud Investigator Resume

Objective : As a Healthcare Fraud Investigator, responsible for triaging and initiating provider investigations related to fraud, waste, and abuse, and developing action plans to address the investigative findings and prevent future loss.

Skills : Investigative, Analytical.

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Description :

  1. Conducted preliminary investigations, involving internal and external research, detailed data analyses, review of medical records, and interviews of members, providers, and other third parties.
  2. Applied laws, regulations, plan policies and guidelines, contract provisions, coding rules, coverage rules, and industry standards to information gathered during the investigation.
  3. Prepared reports of investigative findings and recommended investigative next steps.
  4. Identified root causes of fraud, waste, and abuse and recommended internal and external corrective actions to address these root causes.
  5. Recommended investigative priorities, strategies, and techniques.
  6. Worked with the analytics and intake team to develop and refine data mining to address new and evolving schemes
  7. Shared expertise and promote investigative best practices among SIU management and staff. Educate and collaborate with various business units to raise awareness of potential FWA concerns.
Years of Experience
Experience
0-2 Years
Experience Level
Level
Entry Level
Education
Education
Degree In Criminal Justice


Healthcare Fraud Investigator Resume

Summary : As a Healthcare Fraud Investigator, works closely with other members of the SIU to conduct preliminary investigations of matters identified through data mining or referred to the SIU determine the most appropriate outcome and next steps, and recommend measures to address new and evolving schemes.

Skills : Communication, Healthcare Knowledge.

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Description :

  1. Performed out-of-the-box thinking, collaborate with others, and make a difference every day.
  2. Liaised with relevant internal and external departments to ensure customer queries are dealt with effectively and efficiently.
  3. Prepared accurate documentation for the police or departments to help with investigations.
  4. Ensured decisions and actions complied with company policies and considered the best interests of both the business and the customer.
  5. Reviewed and researched evidence/documents to analyze the overall fact pattern of the claim and synthesize data into a professional report with recommendations.
  6. Wrote in-depth reports on your findings and presented them to management.
  7. Liaising with victims of fraud, the police, and court officials when a civil or criminal case is opened.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
Degree In Healthcare Administration


Healthcare Fraud Investigator Resume

Summary : As a Healthcare Fraud Investigator, provides subject matter expertise on claims and associated fraud risks, helping to ensure effective resolution of investigations. Adheres to relevant security standards, internal and external procedures, and legislative requirements.

Skills : Attention to Detail, Ethical Conduct.

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Description :

  1. Managed and prioritized a large and varied caseload effectively and efficiently to achieve positive results.
  2. Researched and conducted thorough investigations.
  3. Compiled and maintained a document of all investigative procedures.
  4. Interviewed suspects and witnesses to ascertain fraud claims.
  5. Recommended preventive measures and putting in place anti-fraud schemes.
  6. Collected evidence and relevant financial documents to ease fellow investigators' work.
  7. Testified on fraud cases in civil or criminal proceedings.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Degree In Criminal Justice

Healthcare Fraud Investigator Resume

Objective : As a Healthcare Fraud Investigator, responsible for handling claims where fraud is suspected. Performs surveillance, investigates claims, interviews witnesses and suspects, takes photographs, and provides final recommendations.

Skills : Knowledge of evidence collection and preservation.

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Description :

  1. Presented evidence and supporting documentation in court.
  2. Assisted other fraud examiners and private investigators with field assignments.
  3. Conducted timely and unbiased investigations.
  4. Researched evidence and reviewed it for authenticity and accuracy.
  5. Collated all research data into a detailed report.
  6. Coordinated with defense attorneys for disposition strategies.
  7. Monitored bank accounts and financial transactions of victims that claims fraud.
Years of Experience
Experience
2-5 Years
Experience Level
Level
Executive
Education
Education
Degree In Criminal Justice

Healthcare Fraud Investigator Resume

Summary : As a Healthcare Fraud Investigator, used knowledge of healthcare coding conventions, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data and other sources.

Skills : Interviewing witnesses, Research and interrogation skills.

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Description :

  1. Utilized law enforcement resources for investigation assistance.
  2. Supervised investigations conducted by team members.
  3. Reported any possible fraud threats to the senior management.
  4. Prepared report of investigation findings and testified its details in court.
  5. Negotiated with defaulters and responsible parties for recovering losses.
  6. Evaluated potential fraud indicators and the impact of current fraud trends and made recommendations as to appropriate mitigation.
  7. Conducted investigations into allegations of fraud, waste, or abuse committed by clients against our company.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Consultant
Education
Education
Degree In Criminal Justice

Healthcare Fraud Investigator Resume

Objective : As a Healthcare Fraud Investigator, performs in-depth evaluation and makes field-level judgments related to investigations of potential Medicare fraud, waste, and abuse investigations or cases that meet established criteria for referral to the Centers for Medicare & Medicaid for administrative action or to the OIG for criminal action.

Skills : High ethics, Persistence and patience.

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Description :

  1. Reviewed and analyzed claims data and billing documentation for signs of potential fraud, waste, and abuse.
  2. Assisted in the development and implementation of fraud prevention and detection strategies.
  3. Conducted objective, fair, thorough, unbiased, and timely investigations into allegations of fraud, waste, or abuse committed by clients against our company.
  4. Conducted interviews and interrogations to gather additional information and evidence related to suspected fraudulent activities.
  5. Prepared and coordinated field assignments to obtain relevant evidence and information.
  6. Coordinated with defense attorneys to provide deposition strategies and use law enforcement resources for assistance.
  7. Participated in cross-functional teams to investigate and resolve complex fraud cases.
Years of Experience
Experience
2-5 Years
Experience Level
Level
Executive
Education
Education
Degree In Healthcare Administration

Healthcare Fraud Investigator Resume

Objective : As a Healthcare Fraud Investigator, utilizes leads provided by the team and referrals from government and private agencies, works with the team to prioritize complaints for investigation, and then investigates, conducts interviews, and reviews information to make potential fraud determinations.

Skills : Data analytics, Risk assessment.

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Description :

  1. Prepared prosecution packages and restitution proposals.
  2. Provided training and guidance to colleagues on fraud awareness and detection techniques.
  3. Investigated cases of arson, where fires may have been set intentionally to cash in insurance claims.
  4. Examined falsified workers' disability claims.
  5. Set up surveillance and attempt to catch people suspected of fraud in the act.
  6. Investigated possibly staged accidents.
  7. Testified as an expert witness in a court case.
Years of Experience
Experience
0-2 Years
Experience Level
Level
Junior
Education
Education
Degree In Healthcare Administration

Healthcare Fraud Investigator Resume

Objective : As a Healthcare Fraud Investigator, identifies, collects, preserves, analyzes, and summarizes evidence, examines records, verifies the authenticity of documents, and provides information to support the preparation of attestations/referrals, or supervises the preparation of attestations/referrals as needed.

Skills : Intelligence gathering, Fraud measurement.

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Description :

  1. Inspect damaged buildings and automobiles.
  2. Investigated doctors suspected of malpractice.
  3. Created detailed reports documenting incidents.
  4. Performed data analytics to identify fraud, waste, or abuse in claims data.
  5. Responsible for investigating, researching, and analyzing billing data in order to detect fraudulent, abusive, or wasteful activities/practices.
  6. Proactively identified instances of potential fraud, waste, and abuse through data analysis using company systems and tools.
  7. Prepared statistical/financial analysis reports and graphic presentations for notification of findings.
Years of Experience
Experience
2-5 Years
Experience Level
Level
Executive
Education
Education
Degree in Criminal Justice

Healthcare Fraud Investigator Resume

Summary : As a Healthcare Fraud Investigator initiates and maintains communications with law enforcement and appropriate regulatory agencies including presenting or assisting with presenting investigation or case findings for their consideration to further investigate, prosecute, or seek other appropriate regulatory or administrative remedies.

Skills : Investigative and analytical skills.

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Description :

  1. Developed and maintained general knowledge of healthcare reimbursement policies and state and federal regulations related to healthcare fraud and abuse.
  2. Worked cooperatively and constructively with team members, including mentoring, training, and assisting team members as required.
  3. Performed additional duties and projects as assigned by management.
  4. Maintained security and confidentiality of all protected health information encountered in the performance of duties.
  5. Determined investigation or case appropriateness of fraud, waste, and abuse issues in accordance with pre-established criteria.
  6. Referred potential adverse decisions to the Lead Investigator/Manager/Medical Director or designee.
  7. Conducted interviews of witnesses, informants, and subject area experts and targets of investigations.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
Degree In Criminal Justice

Healthcare Fraud Investigator Resume

Summary : As a Healthcare Fraud Investigator, responsible for interviewing individuals with information about the fraud, analyzing the relevant documentation, and reporting their findings. Working in law enforcement, at government agencies, or at financial institutions.

Skills : Testifying in judicial proceedings, Enforcement.

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Description :

  1. Drafted investigation reports, evaluates investigation reports, and promotes effective and efficient investigations.
  2. Testified at various legal proceedings as necessary.
  3. Identified opportunities to improve processes and procedures.
  4. Conducted extensive and confidential investigations of suspected fraud allegations.
  5. Interviewed individuals who may have information on particular fraud allegations.
  6. Ran background checks, employee investigations, and asset searches on suspected perpetrators.
  7. Analyzed documentation, such as victim testimonies and financial records to determine if fraud occurred.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Consultant
Education
Education
Degree In Criminal Justice