163714 - Accredited Health Care Fraud Investigator (AHFI)

Job Description

Job Description

A-Line Staffing is now hiring an Accredited Health Care Fraud Investigator (AHFI)– Remote (Eastern/Central Time Zones)

The SIU Investigator is responsible for investigating reports of non-compliance with corporate and regulatory policies, including fraud, waste, or abuse. As a member of the SIU team, the Investigator helps prevent improper conduct by identifying, assessing, and correcting areas of noncompliance. This role requires judgment, discretion, and professional experience to handle sensitive, high-profile, and complex investigations, including national healthcare fraud schemes.

Accredited Health Care Fraud Investigator (AHFI) Responsibilities:

• Independently analyze internal and public data to determine whether full investigations are warranted.
• Develop investigative strategies and approaches to complete cases.
• Assemble evidence and documentation to support adjudications.
• Conduct on-site audits of provider records to ensure proper billing practices.
• Interview providers, employees, members, and witnesses as part of the investigative process.
• Prepare detailed investigative and audit reports, including metrics, trends, and schemes, for stakeholders and regulatory agencies.
• Coordinate with law enforcement and regulatory authorities as needed.
• Manage a caseload of investigations, track patterns, identify schemes, and report instances of non-compliance.
• Develop new cases based on proactive data mining efforts.
• Provide training regarding Fraud, Waste, and Abuse requirements, Non-Retaliation Policy, Code of Conduct, and government program compliance.
• Perform other related duties as assigned.

Accredited Health Care Fraud Investigator (AHFI)Required Skills & Experience:

• Experience with RATSTATS or similar sampling/extrapolation tools.
• Advanced Excel skills (macros, pivot tables, formulas, Power Query) and ability to analyze large datasets.
• Experience with Microsoft Power BI; SQL knowledge preferred.
• Excellent verbal, written, and presentation skills.
• Ability to work effectively with individuals of diverse backgrounds.
• Knowledge of healthcare payment methodologies and Managed Care products (Medicare, Medicaid, ACA, commercial insurance).
• Experience with FACETs or similar claim systems.
• Strong organizational, analytical, and auditing skills.
• High personal and professional ethics.

Accredited Health Care Fraud Investigator (AHFI)Education & Certifications:

• Required: Bachelor’s Degree; minimum 3 years of healthcare-related experience (healthcare, pharmacy technician, claims adjudication, medical billing/coding, nursing, or law enforcement).
• Preferred: Master’s or Law Degree, CFE or AHFI certification.
• Minimum 2 years of experience conducting comprehensive investigations, preferably involving state, federal, or local law enforcement.

Accredited Health Care Fraud Investigator (AHFI) Schedule & Details:

• Assignment: 12 weeks with potential for extension or conversion
• Location: Remote (must reside in Eastern or Central time zones)
• Shift Hours: Monday – Friday, 8:00 AM – 5:00 PM Eastern
• Equipment will be shipped after compliance clearance; compliance must be completed by 11/10/25 for 11/17/25 start.

If you are interested in this SIU Investigator position, please contact Lindsay at LKOPASZ@ALINESTAFFING.com