Investigator

• Conduct field-based investigations related to Medicaid fraud, abuse, or non-compliance, aligned with UPIC protocols and state-specific Medicaid rules.
• Interview healthcare providers, beneficiaries, and witnesses to gather key case evidence.
• Analyze Medicaid claims, billing patterns, and supporting documentation to identify irregularities or suspicious activity.
• Prepare detailed investigative reports suitable for law enforcement referrals, overpayment recovery, or administrative actions.
• Collaborate with law enforcement entities, state Medicaid agencies, and CMS stakeholders.
• Maintain and manage documentation and case files in compliance with CMS and contractual standards.
• Represent Purisolve with professionalism and discretion during field engagements and stakeholder communications.

Medicaid Investigator focusing on fraud and compliance investigations in Northeast US

Medicaid Investigator – Northeast

Medicaid Investigator focusing on fraud and compliance investigations under NE UPIC contract. Responsible for field investigations and collaborate with law enforcement in the Northeastern US.

• Reviews and analyzes information gathered from databases to investigate alleged financial violations committed by a person or organization, including misuse of funds, misconduct, and corruption
• Prepares investigative reports, presents findings to senior management and relevant stakeholders, and supports control partners by recommending corrective actions to prevent future incidents and improve organizational practices
• Coordinates investigations by providing direction to multiple investigators, identifying issues and control weaknesses, sharing potential recommendations for courses of action, and testifying in court proceedings as needed

Senior Investigator leading financial crime investigations at Bank of America

Senior Investigator

Senior Investigator leading financial crime investigations in diversified operations at Bank of America. Gathering information on financial violations and coordinating investigative tasks.

• Conduct timely investigations including recorded statements and interviews of claimants, witnesses, and employers.
• Provide timely status updates to case manager and client.
• Timely and clear documentation of the claim files.
• Maintain highest level of confidentiality and professionalism.
• Develop appropriate investigative action plan.
• Ensure accuracy, quality and timeliness of the evidence gathered during an investigation as well as compliance with all applicable laws, legal codes, and governing agencies.
• Provide Claim Adjuster with timely investigation results and document investigative findings.
• Determine whether additional evidence is required including but not limited to accident reports, accident scene reconstructions, witness statements, police reports, expert opinion, etc.
• Provide recommendations and decisions surrounding investigative efforts.
• Perform detailed database queries on SIU investigations to include analysis and organization of critical data to assist during the assigned investigation.
• Be able to evaluate State compliance referrals, as applicable, when questionable or suspicious activity is identified.
• Maintain active membership in professional organizations that provide SIU assistance and resources.
• Establish and maintain relationships with law enforcement, government regulatory agencies and insurance industry personnel assisting when needed or required.

Investigates and identifies questionable and suspicious insurance claims at Delta Group

SIU Investigator

Investigates and identifies questionable insurance claims for Delta Group’s partners. Communicating with claims personnel, law enforcement, and regulatory agencies to identify and deter fraud.

• Leads thematic, complex investigative projects and conducts sensitive investigations through analysis of evidence and digital forensics
• Collaborates with human resources, legal, and other business partners for investigative outcomes
• Engages with external law enforcement agencies as required
• Provides mentorship and training ensuring compliance with company, legal, and regulatory requirements
• Acts as the lead on high profile complex investigations and supports executive leadership teams.

Senior Lead Insider Threat Investigator leading complex investigations at TD Bank

Senior Lead Insider Threat Investigator

Senior Lead Insider Threat Investigator at TD Bank leading thematic and complex investigations while collaborating with multiple business partners and law enforcement.

Investigator jobs in New Jersey

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Medicaid Investigator – Northeast

Senior Investigator

SIU Investigator

Senior Lead Insider Threat Investigator