Investigator

• Receives, analyzes and coordinates fraud and abuse complaints from internal sources (customer services, claims processing, underwriting, professional affairs) and external sources (members, providers, state and federal regulatory agencies, law enforcement), then conducts and coordinates moderately complex investigations with expertise across various case types, participating in post-audit exit interviews where appropriate.
• Provides accurate accounting of recovered funds from audit activities, criminal or civil convictions and settlements, demonstrating continuing success in settlement, recovery and collection activities related to fraudulent activity.
• Maintains continuing education through anti-fraud and legal issue seminars, holds at least one professional credential (CPC, CPC-H or CPC-P), reviews pertinent articles and regulatory requirements, and provides post-audit education to providers to correct discrepancies, and trains new Investigators and other Cambia employees in detection of abusive or fraudulent billing practices.
• Assists with maintenance of audit and investigation files, formulation of company policies addressing loss exposures and solutions, and maintains extensive contact with the provider community in both educational and potentially confrontational or adversarial investigative roles.
• Issues audit findings and prepayment claim determinations, including maintaining clear documentation of the basis of findings and determinations, and maintaining the required professional judgment to support and deliver them independently.
• Represents company at external and internal meetings dealing with fraud and abuse issues and litigation proceedings, testifies in court as required, and develops professional working relationships with various associations and agencies for detection of local and national fraud and abuse schemes.
• Conducts witness and target interviews, identifying and analyzing evidence, examining records to verify document authenticity, preparing and evaluating investigation reports, providing information for affidavit preparation, and maintaining communications with law enforcement and regulatory agencies to present case findings for further investigation, prosecution or administrative remedies.

SIU Investigator conducting investigations into fraud and abuse allegations

Special Investigations Unit Investigator II – III

SIU Investigator conducting investigations into fraud and abuse allegations for Cambia Health Solutions. Perform audits and provide investigative support while educating others on fraud prevention.

• Responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud
• Claim reviews for appropriate coding, data mining, entity review, law enforcement referral
• Responsible for identifying and developing enterprise-wide specific healthcare investigations
• Effectively establish rapport and on-going working relationship with law enforcement
• May assist in training of internal and external entities

Investigator II responsible for healthcare fraud investigation and claim reviews

Investigator II

Investigator II investigating healthcare fraud and conducting claim reviews across multiple health plans. Collaborating with law enforcement and assisting in policy development for preventive measures.

• Administer the fraud, waste, and abuse (FWA) duties at an advanced level
• Ensure effective measures are in place and operating effectively to prevent, detect, and correct fraud, waste, and abuse
• Perform advanced level of fraud investigations and provide regular FWA reporting to regulatory agencies
• Help ensure that appropriate procedures are in place and followed consistently to safeguard assets, verify accuracy and reliability of data, and promote efficient operations
• Contribute to the development and operation of an effective FWA program in accordance with CMS requirements and Federal Sentencing Guidelines
• Prepare reports of audit findings and recommendations
• Educate and coach leaders and staff regarding FWA requirements and complex issues
• Participate in completing required Medicare and Medicaid filings and/or responses for FWA

Senior Investigator managing fraud, waste, and abuse responsibilities for CareOregon

Senior Investigator, Investigations Unit

Senior Investigator managing advanced FWA duties and investigations for CareOregon's health plan operations. Developing effective programs to prevent and rectify fraud, waste, and abuse issues.

• administer fraud, waste, and abuse (FWA) duties for CareOregon
• perform fraud investigations
• provide regular FWA reporting
• develop and operate an effective FWA program in accordance with CMS requirements
• perform routine FWA investigations, audits, and corrective actions
• prepare reports of audit findings
• respond to routine and ad hoc requests from external regulatory agencies
• prepare routine and ad hoc reports for internal and external leaders
• assist in developing and maintaining documentation system for FWA regulatory requirements
• review and recommend policy and procedure revisions
• attend internal and external FWA and compliance-related meetings
• assist in providing effective FWA training and education to staff
• educate providers on appropriate documentation and coding

Investigator managing fraud, waste, and abuse for CareOregon

Special Investigations Unit Investigator

Investigator managing fraud, waste, and abuse for CareOregon. Performing investigations, audits, and providing compliance reporting within a healthcare setting.

• The investigator will generate new investigations, and to continue with ongoing investigation and civil actions involving fraud in areas such as healthcare, contracting, and grants, as well as other fraud and abuse of federal public funds and programs.
• Regularly meets with the ACE attorneys and with designated agency personnel for the purpose of generating fraud investigations.
• Performs a variety of ancillary investigations-related services in direct support of any assigned fraud
• Utilizes electronic databases such as public records, property records, business records, and other government-maintained databases, to identify documents, witnesses and other physical evidence.
• Prepares reports on progress of investigations for use by AUSAs and supervisory attorneys. These reports may include significant findings and conclusions, analyses of information located in electronic databases, presentations, recommendations for additional investigative actions and candid assessments of strengths and weaknesses of witnesses, documentary evidence, or other aspects of a case.
• Examines books, ledgers, payrolls, cost reports, billing statements, invoices, correspondence, computer data, and other records pertaining to the transactions, events, or allegations under investigation.
• Performs sophisticated analyses of large-scale hard-copy and electronic data, such as health care claims data, financial transaction data, accounting records, or bank records to develop investigative leads and to determine their potential relevance to the allegations at issue.
• Gathers and analyzes facts including witness statements, timelines, and scientific or technical data for the purpose of advancing investigative objectives. Establishes and verifies relationships between facts and evidence obtained or presented to confirm authenticity of documents, to corroborate witness statements, and to otherwise build proof necessary for successful litigation or settlement.
• Develops and analyzes evidence and collects information relating to such evidence, or other legal matters under consideration, from appropriate primary and secondary sources. Performs analysis to clarify the target suspect's or organization's pattern of operations, to identify information relevant to the legal issues involved, and to recommend valuable approaches to the AUSAs or other members of the investigative team. Develops and refines proof required to assist in determining legal responsibility for violations.
• Assists ACE AUSAs with in-person and/or telephonic interviews of witnesses, depositions, and sworn witness examinations.
• Assists with the preparation and service of subpoenas for documentary materials, interrogatory answers, or witness testimony in connection with ACE investigations.
• Develops an understanding of all applicable federal, state, or local laws to the extent necessary to make sound decisions on direction and scope of investigations. Determines proof required to affix responsibility for violations, and devise methods for obtaining, preserving, and presenting evidence to the greatest effect.
• Assists with determining the most efficacious methods for planning, scheduling, and conducting investigations, and identifies any resources that may be required.
• Performs other related ACE investigator duties as assigned and within scope.
• Attends meetings and trainings as may be required and appropriate.

ACE Investigator supporting federal agency fraud detection and investigations

Civil Enforcement Investigator

ACE Investigator supporting government innovation through fraud detection and investigations. Joining a team dedicated to solving dynamic government challenges with technology.

• Detect and investigate attempts to misuse Anthropic's AI systems for cyber operations
• Develop abuse signals and tracking strategies to proactively detect sophisticated threat actors
• Create actionable intelligence reports on new attack vectors, vulnerabilities, and threat actor TTPs
• Conduct cross-platform threat analysis using open-source research, dark web monitoring, and internal data
• Implement systematic improvements to safety approach based on investigation findings
• Study trends to anticipate how AI systems could be misused
• Build and maintain relationships with external threat intelligence partners
• Work cross-functionally to build out threat intelligence program

Technical Cyber Threat Investigator on Threat Intelligence team at Anthropic

Technical Cyber Threat Investigator

Technical Cyber Threat Investigator responsible for detecting and investigating misuse of AI systems at Anthropic. Collaborating with cross-functional teams to enhance cybersecurity measures against emerging threats.

• Detect and investigate attempts to misuse Anthropic's AI systems for CBRN-E threats
• Conduct technical investigations using SQL, Python, and other tools
• Develop CBRN-E-specific detection capabilities
• Create actionable intelligence reports on CBRN-E attack vectors
• Conduct cross-platform threat analysis grounded in real threat actor behavior
• Collaborate with policy and enforcement teams for informed decisions
• Engage with external stakeholders including government agencies
• Inform safety-by-design strategies regarding AI technology misuse

Technical CBRN-E Threat Investigator at Anthropic's Threat Intelligence team

Technical CBRN-E Threat Investigator

Technical CBRN-E Threat Investigator detecting and investigating misuse of AI systems for threats. Collaborating with diverse teams to protect against CBRN-E misuse and developing detection techniques.

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