Claims Investigation Services Senior Consultant
Core
Lead complex investigations into suspected fraud, abuse, and provider misconduct in Supplemental Health claims while overseeing department quality control and audit processes.
Role type
Senior Claims Investigation Consultant (Fraud & Quality)
Builds
Fraud detection methodologies, investigation playbooks, and quality assurance protocols for Supplemental Health products.
Domain
Insurance (Supplemental Health) / Fraud Investigation / Claims Operations
Deliverable
client delivery | production ML models (via partnership) | dashboards & analysis
Required skills
complex investigation leadership, medical record review, claims documentation analysis, fraud pattern identification, audit execution, regulatory compliance support, financial exposure quantification, training development
Preferred skills
subject matter expertise in Supplemental Health fraud, ability to present findings to senior leadership, development of investigation playbooks and best practices
Technologies
Claims analytics tools, fraud detection systems, medical record management systems
Responsibilities
Lead investigations involving suspected fraud, abuse, provider misconduct, and organized fraud schemes; Conduct quality audits of staff-processed claims to ensure adherence to guidelines; Partner with Data Science teams to develop fraud detection methodologies; Coordinate medical record procurement and evidence gathering; Support regulatory inquiries and legal proceedings; Train claims professionals on fraud indicators and escalation triggers
Seniority
Senior, hands-on IC with mentorship responsibilities
