Fraud Investigator II

Make a Meaningful Impact in Healthcare Integrity. At ForHealth Consulting, we partner with mission-driven organizations to create a healthcare system that is more equitable, effective, and accessible. If you're motivated by meaningful work-and enjoy digging into data to uncover trends, patterns, and hidden problems-this role offers both purpose and challenge.

As a Fraud Investigator II, you'll play a key role in protecting the integrity of the Massachusetts Medicaid program. You will analyze claims data, lead complex investigations to uncover fraudulent practices, and ensure taxpayer dollars are used appropriately. This position sits at the intersection of data analytics, healthcare operations, and compliance, offering the chance to make a real difference for vulnerable populations.

Enjoy a flexible hybrid schedule, excellent state benefits, and the opportunity to expand your expertise in a supportive, collaborative environment.

Hybrid requirement ** - Once a month on site.

MAJOR RESPONSIBILITIES:

Use your expert knowledge of Medicaid regulations, healthcare policies, and industry standards to perform independent data mining and analysis to identify outliers, trends, and suspicious billing activity.
• Build sophisticated algorithms, queries, and reports to detect fraud, waste, and abuse.
• Review large volumes of claims to ensure compliance with regulations, policies, and contract terms.
• Prepare clear, accurate investigative reports; calculate overpayments; and issue findings based on agency procedures.
• Communicate directly with providers regarding audit results, recoveries, and education opportunities.
• Recommend improvements to policies, systems, and analytical tools to enhance FWA detection.
• Mentor Investigator I staff and serve as a resource for complex or specialized algorithms.
• Keep leadership updated on case progress and propose new investigative initiatives.
• Manage all case documentation in the tracking system with accuracy and timeliness.
• Contribute to special projects and department-wide integrity initiatives as needed.

REQUIRED QUALIFICATIONS:

• A Bachelors' degree in Business administration, finance, public health or related field; or equivalent years of experience.
• 5-7 years of related experience in fraud examination, healthcare, business, finance or related field; with at least 2 years of experience conducting data mining in the healthcare insurance industry and claims related experience.
• Knowledge of coding, reimbursement and claims processing policies.
• Knowledge of the principles and practices of medical auditing.
• Strong analytical and qualitative skills as well as problem solving skills with the ability to look for root causes and implement workable solutions.
• Knowledge of the law and regulations as it relates to fraud and fraud investigations.
• Must have a track record of producing high quality work that demonstrates attention to detail.
• Ability to multi-task, establish priorities and work independently to achieve objectives.
• Ability to function effectively under pressure.
• Proficient in Microsoft Office applications (Word, Excel, PowerPoint and Access)
• Excellent Customer service skills with the ability to interact professionally and effectively with providers, third party payers, and staff from all departments.
• Strong Interpersonal skills with the ability to work in a fast paced environment whether as a team member or an independent contributor.
• Strong oral and written communication skills including internal and external presentations.

PREFERRED QUALIFICATIONS:

• Prefer individual possessing the following certification: CPC
• Advanced Microsoft Excel software skills.
• Knowledge of State and federal regulations as they apply to public assistance programs
• Strong Decision-making skills with the ability to investigate and weigh alternatives and select the appropriate course of action.
• Creative thinking skills with the ability to ask the needed "bigger- picture" questions that lead to process and team improvements.

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