Senior Investigator

PacificSource Health Plans

Senior Investigator managing fraud, waste, and abuse audits across independent teams at PacificSource. Conducting investigations and ensuring compliance with regulations and company policies.

Posted 7/15/2026full-timeRemote • North Carolina • 🇺🇸 United StatesSenior💰 $65,296 - $111,004 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting healthcare fraud investigations, utilizing analytic resources and OSINT tools to identify and address Fraud, Waste, and Abuse. Proficient in regulatory reporting, case management, and effective communication with stakeholders.

Highest-signal resume keywords

Healthcare Fraud InvestigationsAudit FacilitationOSINT Tools UtilizationRegulatory ReportingCertified Fraud Examiner (CFE)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Healthcare Claims Data AnalysisInvestigative DocumentationFact-Finding InterviewsPattern IdentificationCase Management

Soft Skills

Effective CommunicationCollaborationTraining Development

Tools & Technologies

OSINT PlatformsClaims Management Systems

Certifications & Qualifications

Certified Fraud Examiner (CFE)

Industry Keywords

Fraud, Waste, and Abuse (FWA)Regulatory ComplianceHealthcare AuditingCriminal JusticeBusiness Administration

Tech Stack

Tools & technologies

Open Source

About the role

Key responsibilities & impact

Independently plan, conduct, and manage prompt, thorough onsite and desk-top investigations of health care claims.
Thoroughly document investigative findings and actions to create comprehensive case files in accordance with established policies and procedures.
Proactively utilize available analytic resources to identify patterns of potential Fraud, Waste and Abuse, initiating audits when necessary.
Conduct fact-finding interviews with internal staff, external providers, patients and other relevant parties regarding medical and behavioral health services initiating investigations when necessary.
Utilize available Open Source Intelligence (OSINT) tools to verify provider licenses, research criminal history, disciplinary actions, financial assets and liabilities.
Attend and participate in regional FWA Task Force and other state or federal meetings.
Establish and maintain a comprehensive knowledge and understanding of current state and federal reporting requirements ensuring FWA reporting is received, summarized, catalogued, and disseminated to the appropriate agencies.
Ensure regulatory reporting is developed, accurate, and submitted timely.
Serve as an internal Subject Matter Expert (SME) on matters related to auditing and FWA.
Develop and conduct internal FWA related training.
Collaborate with government agencies during audits, investigations and Requests for Information (RFI).
Present and discuss case findings and recommendations in case review meetings with department and company management.
Participate in the development and presentation of FWA reporting for the Corporate Compliance Committee and the Audit and Compliance Committee of the Board.
Coordinate and manage the production of investigative materials in support of settlement negotiations.

Requirements

What you’ll need

Minimum of 4 years of experience conducting complex healthcare fraud investigations required.
Significant experience in facilitating audit activities across specialized teams required.
Ability to effectively and professionally communicate with internal and external stakeholders, in both written and verbal form, required.
Ability to independently research, understand and interpret complex healthcare claims data, civil and criminal laws, and contract requirements required.
Experience in navigating case management, claims and OSINT platforms preferred.
Bachelor’s degree in business administration, criminal justice, or related field or a combination of equivalent education and experience is required.
Ability to obtain Certified Fraud Examiner (CFE) or equivalent certification within 24 months of employment required.

Benefits

Comp & perks

Flexible telecommute policy
Medical, vision, and dental insurance
Incentive program
Paid time off and holidays
401(k) plan
Volunteer opportunities
Tuition reimbursement and training
Life insurance
Options such as a flexible spending account