Healthcare Fraud Investigator

Council Capital • Nashville, TN

4d • Remote

About The Position

Alivia Analytics helps healthcare payers find and recover improper payments. Our payment integrity platform pairs analytics with expert review to surface fraud, waste, and abuse across Medicare, Medicaid, Commercial, and FHP lines of business, returning significant value to the clients we serve. We are scaling our service organization to keep pace with new client demand, and this role is part of that build-out. This is a hunt-and-close role. You will identify and qualify improper-payment leads, then own each one end to end, from concept through an accepted case to recovered dollars. You will carry a live caseload, drive it to closure, and be measured on the revenue you return. You will work directly with payer clients and partner with coders and customer success, but you will not manage anyone. Strong investigators here come from healthcare payer/vendor backgrounds or from investigative and law-enforcement backgrounds paired with real healthcare-claims depth.

Requirements

• 2+ years at a healthcare payer or vendor as an Investigator or Auditor working with healthcare claims.
• Experience across multiple lines of business (Medicare, Medicaid, Commercial, FEP).
• Proficiency with auditing software, case management systems, and claims systems.
• Experience owning the full investigation workflow, from lead to revenue.
• Sound analytical judgment and the ability to negotiate favorable, defensible outcomes.
• U.S.-based with work authorization (no offshore; PHI environment).

Nice To Haves

• Certified Fraud Examiner (CFE).
• Certified Professional Coder (CPC).
• Accredited Health Care Fraud Investigator (AHFI).
• Certified Anti-Fraud Professional (CAFP).
• Based in an Eastern or Central time zone.

Responsibilities

• Identify and qualify 100%+ of budgeted leads each month (roughly 15), taking each from concept to an accepted lead.
• Earn at least 50% lead acceptance/concept approval from clients.
• Carry an active caseload of 20 to 30 cases per month, owning each case from open to close.
• Close 90% of individual cases within four to five months.
• Convert case value into recovered dollars, hitting at least 100% of your top-line revenue target (roughly 45% of identified value converting to gross revenue).
• Maintain a 95% first-time acceptance rate on documentation sent to customers.
• Keep payer complaints at zero and minimize provider abrasion across every interaction.
• Work fluently across Medicare, Medicaid, Commercial, and FEP lines of business.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed