Job Description
This job is about catching healthcare fraud and making sure it gets handled the right way. People send in tips when they think a doctor, clinic, or company might be cheating the system. This person is the one who receives those tips, decides how serious they are, and sends them to the right team. They also have to report certain cases to the government on time, which is a big deal. If reports are late or wrong, the company can get in trouble. They use data and billing codes to spot suspicious patterns and help investigators do their jobs. They also help train others and answer questions because they are very experienced. In short, they are the gatekeeper and organizer for fraud cases, and they make sure everything is tracked, analyzed, and reported correctly.
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.
Required Skills & Experience
Education: Associate’s required (or equivalent experience); Bachelor’s preferred
Experience:
• 4+ years in healthcare fraud investigation/detection
• Experience with Medi-Cal/Medicare/Medicaid reporting preferred
Skills
• Strong analytical and data interpretation skills
• Expertise in regulatory reporting and compliance requirements
• Advanced proficiency in Excel and familiarity with HCFS, HPMS, and other systems
• Knowledge of healthcare coding (CPT, HCPCS, ICD-10) and billing processes
• Strong project management, organization, and communication skills
Certifications (Preferred)
• Certified Medical Coder
• Accredited Healthcare Fraud Investigator (AHFI)
Nice to Have Skills & Experience
Core Responsibilities
Intake & Triage
• Oversee intake and prioritization of investigative leads (hotline, email, law enforcement, regulatory referrals)
• Evaluate and route cases to appropriate internal teams or partner organizations (PPs/PPGs)
• Document and track all cases in the HCFS case management system
Regulatory Reporting & Compliance
• Prepare and submit required reports to CMS and DHCS within strict timelines (e.g., 10-day requirement)
• Serve as primary point of contact for regulatory agencies
• Ensure adherence to federal/state reporting requirements and internal policies
Data Analysis & Investigation Support
• Analyze claims, provider data, and fraud indicators to identify suspicious patterns
• Support investigators with analytics and reporting for complex cases
• Apply knowledge of coding (CPT, HCPCS, ICD-10), fraud schemes, and reimbursement models
Systems & Process Ownership
• Serve as SME for HCFS and reporting systems, driving enhancements and system improvements
• Lead development and optimization of reporting functions and workflows
Leadership & SME
• Train and mentor junior staff on intake processes and reporting standards
• Provide guidance on fraud detection, regulatory compliance, and best practices
Benefit packages for this role will start on the 1st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.