Fraud Investigator

• Adjudicate loans flagged for potential fraud.
• Implement loan review procedures that include a manual quality control review process for all loan investigations and dispositions.
• Leverage RFPs and subsequent documentation provided by borrowers/lenders to review bank records, tax records, payroll records, incorporation records, and other documentation for potential fraud or falsification.
• Conduct research via open source methods including government databases (OFAC, SAM, Secretaries of State, etc.) as well as commercial databases and Internet sources.
• Use commercial databases such as LexisNexis, CLEAR, Duns & Bradstreet, etc. for purposes of conducting fraud investigations.
• Use a case management system with productivity goals and oversight expectations.
• Assist with pulling data within <24 hours for documentation requests made by the U.S. Treasury Department, U.S. Congress, SBA OGC, and SBA OIG.
• Assist SBA with drafting responses to inquiries or findings made by government agencies and oversight committees such as the PRAC, GAO, and SBA OIG.
• Assist SBA with drafting responses to requests made by external oversight reviewers related to SBA financial audits, fraud risk assessments, or other PPP evaluations.
• Assist SBA with updating and maintaining PPP policies and procedures.
• Provide detailed daily and weekly reporting on investigative activities.
• Other duties as assigned.

Fraud Investigator IV focused on fraud detection for pandemic relief programs

Fraud Investigator – IV

Fraud Investigator IV responsible for detecting fraud in pandemic relief programs. Conducting investigations and ensuring compliance with federal regulations.

• Conduct investigations into suspected fraud involving debit cards, deposits, checks, ACH, wires, online banking, and other channels
• Review account activity, transaction patterns, and supporting documentation to assess the validity of fraud claims
• Gather and evaluate evidence from customers, internal systems, external institutions, and third-party sources
• Contact customers as needed to obtain information, clarify transactions, and obtain supporting documents
• Document all case activity, findings, and determinations accurately and within required timeframes using the fraud management system
• Prepare and submit required reports (e.g., IC3) in accordance with internal guidelines
• Prepare Letters of Indemnity (LOI), Hold Harmless Letters (HHL), and other fraud-related correspondence; follow up with external institutions as necessary
• Ensure all investigative actions comply with bank policies, regulatory requirements, and applicable frameworks (e.g., Regulation E, NACHA, BSA/AML, card network rules)
• Communicate with customers to gather facts, confirm activity, and support case resolution
• Provide ongoing communication and support throughout the investigation process
• Deliver professional and empathetic service, particularly when customers have experienced financial loss
• Explain investigation outcomes, including approvals and denials, in a clear and supportive manner
• Educate customers on fraud prevention and account security best practices
• Partner with internal teams (e.g., Fraud Agents, Online Banking, Card Services, Deposit Operations, Branch Leadership) to support investigations and resolutions
• Coordinate with Legal, Corporate Security, and Compliance on cases involving law enforcement, subpoenas, or regulatory matters
• Escalate high-risk, complex, or emerging fraud trends to leadership
• Share insights to help improve fraud prevention strategies and customer experience
• Maintain accurate, complete, and compliant case records aligned with regulatory and internal requirements
• Ensure adherence to all operational procedures and regulatory requirements
• Manage a high volume of cases while maintaining accuracy and attention to detail
• Balance investigative work with customer communication (inbound and outbound)
• Complete investigations within required timelines
• Produce well-supported, defensible decisions aligned with policy and evidence
• Maintain clear, audit-ready documentation
• Identify and pursue recovery opportunities when applicable
• Participate in all required compliance training, including Bank Secrecy Act/anti-money laundering training, as well as internal and external training programs, online training, meetings, and seminars/conferences, etc.

Fraud Investigator I investigating fraud claims for a bank

Fraud Investigator I

Fraud Investigator I protecting customers from financial loss by investigating fraud claims and suspicious activity across various banking channels. Ensuring compliance and timely case resolution through strong analytical skills.

• Performs comprehensive analysis and clinical evaluation of the collected data
• Performs in-depth investigations on identified providers as warranted
• Examines claims for compliance with relevant billing and processing guidelines
• Review and conducts retrospective analysis of claims and medical records prior to payment
• Researches new healthcare related questions as necessary to aid in investigations
• Collaborates with the Special Investigation Unit and other internal areas on matters of mutual concern
• Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation

Clinical Fraud Investigator II analyzing clinical data for fraud in healthcare

Clinical Fraud Investigator II

Clinical Fraud Investigator II at Elevance Health assessing healthcare claims for fraud and compliance issues. Collaborating with internal teams and conducting retrospective analysis of claims and medical records.

• Conduct investigations of allegations of fraudulent and abusive practices
• Coordinate investigation with law enforcement authorities
• Assemble evidence and documentation to support successful adjudication
• Conduct on-site audits of provider records ensuring appropriateness of billing practices
• Prepare complex investigative and audit reports
• Understand department, segment, and organizational strategy and operating objectives
• Make decisions regarding own work methods, occasionally in ambiguous situations

Fraud and Waste Investigator conducting investigations for Humana

Fraud and Waste Investigator

Fraud and Waste Investigator at Humana analyzing healthcare fraud allegations and coordinating investigations. Preparing evidence and audit reports with a focus on billing practices.

• Conduct complex criminal and civil investigations into allegations of fraud and abuse in the Medicaid program.
• Review complaints against providers and access Medicaid claims for data analysis.
• Research program rules and regulations and develop investigative plans.
• Analyze financial records and review medical records.
• Interview witnesses and conduct surveillance.
• Serve subpoenas, help execute search warrants, and draft investigative reports and memos.
• Collect and secure evidence and conduct public records searches.
• Serve as a witness in criminal and civil proceedings.
• Perform other investigative tasks necessary to root out fraud, waste, and abuse.

Investigator conducting fraud investigations within Medicaid Fraud Division

Investigator I, Investigator II, Investigator III

Investigator conducting complex investigations into Medicaid fraud and healthcare abuse in Boston, Massachusetts. Reviewing complaints, analyzing data, and performing investigative tasks as part of a hybrid team.

Fraud Investigator jobs in United States

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Fraud Investigator – IV

Fraud Investigator I

Clinical Fraud Investigator II

Fraud and Waste Investigator

Investigator I, Investigator II, Investigator III