Top 158 Fraud investigator Jobs in Florida

Special Investigation Unit (SIU) Lead/Investigator (Medicare Advantage Plan)
Ultimate Health Plans —Tampa, FL
- From $75,000 a year
- Full-time
- Anatomy knowledge
- Microsoft Excel
- Microsoft Outlook
- Health insurance
- Dental insurance
Quick Apply
Investigator, Special Investigative Unit
Molina Healthcare —Jacksonville, FL
- $21.82 - $42.55 an hour
- Full-time
- Anatomy knowledge
- Customer service
- Research
- Health insurance
Investigator, Special Investigative Unit Coding-Miami Florida
Molina Healthcare —Saint Petersburg, FL
- $21.82 - $42.55 an hour
- Full-time
- Anatomy knowledge
- Clinic experience
- Research
- Health insurance
SIU Investigation Senior Adjuster
National General —Jacksonville, FL
- $70,000 - $138,600 a year
- Online Application
- Remote
- Bachelor's degree
- US work authorization
- Fair chance
9d
SIU Investigator - Tampa Bay Area
Allied Universal® Compliance and Investigations —Tampa, FL
- Weekends as needed
- Military
- Computer literacy
- High school diploma or GED
- AD&D insurance
- Paid holidays
Quick Apply
9d
Fraud and Abuse Investigator / CPC - Remote
Sentara Workforce Solutions, LLC —Tallahassee, FL
- $25.60 - $42.67 an hour
- Overtime
- Remote
- Mid-level
- Bachelor's degree
- 2 years
- 403(b) matching
- Paid parental leave
Quick Apply
4d
SIU Investigator
Centene —Florida
- $56,200 - $101,000 a year
- Full-time
- Remote
- Mid-level
- Fair chance
- 1 year
- Paid holidays
- Health insurance
Corporate Ethics & Compliance Investigator
Centene —Florida
- $107,700 - $199,300 a year
- Full-time
- Remote
- 7 years
- Management
- HIPAA
- Paid holidays
- Health insurance
Fraud Investigator I
Navy Federal Credit Union —Pensacola, FL
- $25.34 - $34.09 an hour
- Online Application
- Word processing
- Research
- Mid-level
5h
Fraud Investigator
Seacoast Bank —Florida
- Writing skills
- Mid-level
- 3 years
Quick Apply
4d
Internal Major Case SIU Investigator
GEICO —Lakeland, FL
- Full-time
- Mentoring
- Typing
- Senior level
Investigator 2, Security
Comcast Corporation —Sarasota, FL
- Full-time
- Bilingual
- Microsoft Excel
- 5 years
Fraud Investigator I
Space Coast Credit Union —Miramar, FL
- $28.13 - $29.79 an hour
- Hybrid work
- Pass drug screening
- Mid-level
- Office
- Health savings account
- Disability insurance
Quick Apply
Investigator, Special Investigations Unit (Meritain Health)
CVS Health —Tallahassee, FL
- $46,988 - $122,400 a year
- Full-time
- Customer service
- Research
- Mid-level
- Health insurance
- Dental insurance
Senior Investigator, Special Investigations Unit (Aetna SIU) - Must reside in Florida
CVS Health —Plantation, FL
- $46,988 - $102,000 a year
- Full-time
- Microsoft Excel
- Microsoft Outlook
- Customer service
- Health insurance
- Dental insurance
Entry-Level Investigator
Ethos Risk Services —Palm Bay, FL
- $20 - $26 an hour
- Weekends as needed
- Computer literacy
- Writing skills
- No experience needed
- Paid training
- Mileage reimbursement
Quick Apply
SIU Investigator
Kemper Insurance —Miami, FL
- Full-time
- Clean driving record
- Mid-level
- Residential
Quick Apply
9d
Citi Security and Investigative Services (CSIS) Senior Investigator- AVP
Citi —Tampa, FL
- $87,360 - $131,040 a year
- Weekends as needed
- Hybrid work
- Microsoft Outlook
- CPA
- 5 years
- Paid holidays
- Disability insurance
2d
SIU Desk Investigator - Miami
AssuranceAmerica —Florida
- Full-time
- Customer service
- Mid-level
- Office
Field Investigator (FT & PT) – Orlando/Tampa, FL
Origin Investigations Inc —Tampa, FL
- $20 - $35 an hour
- Part-time
- Background check
- Military
- High school diploma or GED
Quick Apply

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fraud investigator jobs near florida

Special Investigation Unit (SIU) Lead/Investigator (Medicare Advantage Plan)

Ultimate Health Plans -
Tampa, FL

Quick Apply

Job Details

Full-time
From $75,000 a year

Benefits

Health insurance
Dental insurance
401(k)
Vision insurance
401(k) matching

Qualifications

Healthcare financial misconduct investigations
Customer communication
Anatomy knowledge
Microsoft Excel
Investigations regulatory compliance
Microsoft Outlook
Medicare
Managed care
Customer service
Managed care organization experience
Writing skills
Health insurance policy knowledge
Presentations for conferences or internal meetings
Investigative data analysis
Driver's License
Insurance regulation
Healthcare regulatory compliance research
Medicare regulations
Risk management
SharePoint
Medicaid regulations
Medicaid
Healthcare claims compliance audits
Research findings presentation
Medical terminology
Professional development training

Full Job Description

Company Overview

CSTS Customer Service and Technology Solutions LLC is a dedicated third-party administrator specializing in managing the administrative and operational functions for insurance plans. Our mission is to revolutionize the healthcare experience by delivering exceptional products and services to our partners, ensuring compliance and efficiency at every step.

Position Overview

CSTS is seeking an experienced and highly The SIU Lead/Investigator is responsible for supporting the prevention, detection, investigation, reporting (when appropriate), and recovery of money related to health care Fraud, Waste, and Abuse (FWA). The SIU Lead is accountable for managing the day-to-day SIU activities. This position will ensure compliance with federal and state guidance related to FWA, and for reviewing and analyzing information to draw conclusions on allegations of FWA and/or may determine appropriateness of care.

Job Duties

Responsible for developing leads presented to the SIU to assess and determine whether potential FWA is corroborated by evidence.
Claims review for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims.
Lead investigation caseloads, document all case files appropriately to meet regulatory guidelines. Completing investigations within the mandated period of time required by state and/or federal contracts and/or regulations.
Communicate orally and in writing with all customers, internal and external, regarding findings.
Prepare reports to document findings and maintain up-to-date case files for management review.
Collaborate with other departments within UHP and outside vendors to ensure the success of the UHP SIU program.
Provide inter-departmental input regarding controls for preventing and monitoring FWA issues.
Develop strategies to create and maintain a FWA Unit that has the flexibility, knowledge, situational awareness, and capacity to successfully address the dynamic FWA environment.
Provide recommendations or intervention strategies to correct and/or prevent abusive practices, including proposals to recover inappropriately paid monies or to suspend or terminate program participation.
Lead the development and delivery of educational awareness and training programs for the organization and providers.
Maintain outcome-focused SIU Policies & Procedures that are consistent with all applicable contractual and regulatory requirements.
Develop and maintain a high degree of rapport and cooperation with the Federal, State, and local law enforcement and regulatory agencies which can assist in investigative efforts.
Prepares appropriate FWA referrals to regulatory agencies and law enforcement.
Present provider review findings to internal and external entities as requested.
Other duties as assigned

Job Qualifications

Required Education

Bachelor’s degree or associate degree, in criminal justice or equivalent combination of education and experience.

Required Experience/Knowledge, Skills & Abilities

1-3 years of Medicare managed care compliance and/or investigation experience, unless otherwise required by state contract.
Proven investigatory skill; ability to organize, analyze, and effectively determine risk with corresponding solutions; ability to remain objective and separate facts from opinions.
Knowledge of Managed Care and the Medicaid and Medicare programs.
Understanding of claim billing codes, medical terminology, anatomy, and health care delivery systems.
Understanding of datamining and use of data analytics to detect fraud, waste, and abuse.
Proven ability to research and interpret regulatory requirements.
Effective interpersonal skills and customer service focus; ability to interact with individuals at all levels.
Excellent oral and written communication skills; presentation skills with ability to create and deliver training, informational and other types of programs.
Excellent skills in Microsoft Office (Word, Excel, PowerPoint, Outlook), SharePoint and Intra/Internet as well as proficiency with incorporating/merging documents from various applications.
Strong logical, analytical, critical thinking and problem-solving skills.
Initiative, excellent follow-through, persistence in locating and securing needed information.
Fundamental understanding of audits and corrective actions.
Detail-oriented, self-motivated, able to meet tight deadlines.
Ability to develop realistic, motivating goals and objectives, track progress and adapt to changing priorities.
Collaborative and team-oriented

Required License, Certification, Association:

Valid driver’s license required.

Preferred Experience:

At least 5 years of experience in FWA and/or compliance in Medicare managed care organizations is required.

Preferred License, Certification, Association:

Health Care Anti-Fraud Associate (HCAFA)
Accredited Health Care Fraud Investigator (AHFI)
Certified Fraud Examiner (CFE)

CSTS is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Pay: From $75,000.00 per year

Benefits:

401(k)
401(k) matching
Dental insurance
Health insurance
Vision insurance

Application Question(s):

How many years of Medicare Advantage experience do you have?
Can you describe your experience with Medicare or Medicaid fraud and waste investigations?
How do you prioritize and manage your workload when dealing with multiple fraud cases at once?

Work Location: In person

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Refine Your Search

fraud investigator jobs in florida

Special Investigation Unit (SIU) Lead/Investigator (Medicare Advantage Plan)

Investigator, Special Investigative Unit

Investigator, Special Investigative Unit Coding-Miami Florida

SIU Investigation Senior Adjuster

SIU Investigator - Tampa Bay Area

Fraud and Abuse Investigator / CPC - Remote

SIU Investigator

Corporate Ethics & Compliance Investigator

Fraud Investigator I

Fraud Investigator

Internal Major Case SIU Investigator

Investigator 2, Security

Fraud Investigator I

Investigator, Special Investigations Unit (Meritain Health)

Senior Investigator, Special Investigations Unit (Aetna SIU) - Must reside in Florida

Entry-Level Investigator

SIU Investigator

Citi Security and Investigative Services (CSIS) Senior Investigator- AVP

SIU Desk Investigator - Miami

Field Investigator (FT & PT) – Orlando/Tampa, FL

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