Fraud and Waste Investigator
Core
Conduct comprehensive investigations of reported, alleged, or suspected fraud, waste, and abuse involving South Carolina's Medicaid Program, including on-site audits of provider records and analysis of billing practices.
Role type
Senior IC fraud and waste investigator (healthcare)
Builds
Investigative reports, audit findings, and evidence packages for adjudication
Domain
Healthcare / Medicaid / Insurance
Required skills
Healthcare fraud investigation, auditing, billing practice analysis, evidence preservation, data analysis, clinical knowledge, report writing, law enforcement coordination
Preferred skills
Graduate degree, certifications (MBA, J.D., MSN, CPC, CFE), claims processing experience, business operations understanding
Technologies
MS Office, Excel, Access
Responsibilities
Analyze healthcare payment methodologies and reimbursement structures to detect irregularities; Assemble, organize, and preserve evidence for case resolution; Conduct on-site audits of provider records; Coordinate investigations with law enforcement and regulatory agencies; Prepare complex investigative summaries and formal reports; Review claims, provider billing patterns, and medical records to identify potential fraud, waste, or abuse.
Seniority
Mid-Senior level, hands-on IC
