CLAIMS INVESTIGATOR JOB DESCRIPTION

Managed care plans and Medicaid-funded programs lose billions annually to improper billing, yet recovering those funds depends on someone doing meticulous, case-by-case investigative work. When that work is absent or inconsistent, overpayments go undetected, provider corrective actions stall, and compliance exposure compounds across an entire network. A Claims Investigator in this space owns the full arc from data anomaly to disposition: pulling claims, cross-referencing CPT and ICD-10 codes, reviewing medical records, and presenting findings to compliance leadership or, when required, to state regulators and court proceedings. Not many roles require both the analytical discipline to read a billing code set and the judgment to recommend settlement or referral.

As the Claims Investigator, you are accountable for detecting fraud, waste, and abuse across provider and member claims populations within a managed care or Medicaid-funded plan, translating evidence into documented findings that directly inform overpayment recovery and corrective action decisions. You operate within a Special Investigations or Program Integrity unit, working alongside compliance officers, senior investigators, and legal counsel to prioritize cases, meet audit timelines, and ensure provider conduct aligns with federal and state Medicaid regulations.

Career Impact: Earning credentials such as the Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE) while working active Medicaid and managed care cases builds a level of forensic healthcare expertise that commands strong market value across payers, state agencies, and consulting firms.

Business Impact: The overpayments you identify and recover directly protect plan reserves and preserve service funding for the member populations the organization serves, outcomes that show up in audited financials and regulatory compliance reports.

Growth Opportunity: Investigators who develop proficiency in claims adjudication standards, fraud analytics, and Medicaid regulatory interpretation move into senior investigator, Special Investigations Supervisor, or Program Integrity Director roles, each with expanded case authority and broader policy influence.

• Review provider and facility claims alongside supporting medical records to assess billing accuracy against CPT, HCPCS, ICD-10, and applicable revenue codes.
• Develop audit and investigation plans using data analytics, allegations, and prior audit history to target areas of potential fraud, waste, or abuse.
• Conduct structured interviews with providers, employees, recipients of services, and witnesses to gather evidence in support of or against an allegation.
• Analyze claims data from multiple sources, including authorizations, credentialing records, and incarceration or incident reports, to detect billing irregularities beyond the initial allegation.
• Document findings, overpayment calculations, and disposition recommendations in written audit and investigation reports submitted to compliance leadership and, where applicable, state regulators.
• Coordinate corrective action follow-through by providing provider education, tracking probation compliance, and preparing technical assistance where full investigation is not warranted.
• Support appeal proceedings and, when required, court hearings by presenting and defending audit findings with clear, evidence-based rationale.
• Collaborate with the Special Investigations Unit, Senior Management, and General Counsel to align case handling with federal and state Medicaid statutes and internal compliance policies.

• Bachelor's degree in healthcare administration, business, criminal justice, healthcare compliance, or a related field, or equivalent work experience.
• 3 or more years of experience in healthcare claims investigation, managed care compliance, or medical records auditing, with demonstrated knowledge of fraud, waste, and abuse detection.
• Proficiency in healthcare coding systems, including CPT, HCPCS, ICD-10, and DRG codes, sufficient to independently evaluate billing appropriateness.
• Working knowledge of federal and state Medicaid laws, claims adjudication standards, and provider contractual obligations under managed care agreements.
• Strong analytical and investigative skills, with the ability to identify patterns across large claims datasets and draw logical, well-documented conclusions.
• Excellent written and verbal communication skills, including the ability to produce clear audit reports and deliver provider education to varied audiences.
• High degree of integrity and discretion in handling confidential medical, personnel, and investigative records.

• Certification as an Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or Certified in Healthcare Compliance (CHC).
• Experience conducting post-payment audits of Medicaid or state-funded behavioral health providers, including inpatient, residential, and intensive outpatient settings.
• Familiarity with fraud analytics platforms, SQL querying, or data visualization tools used to surface billing anomalies at scale.
• Prior involvement in provider appeal proceedings, state agency reporting, or court-based evidentiary presentations.

• Overpayment recovery rate per audit cycle, measuring dollars identified and recouped as a share of reviewed claims volume.
• Case closure timeliness, tracking percentage of investigations resolved within established program integrity SLA windows.
• Coding accuracy of findings, assessed through supervisory review of CPT, HCPCS, and ICD-10 determinations across completed audit reports.
• Provider corrective action completion rate, reflecting follow-through on probation terms and technical assistance plans assigned post-audit.
• Allegation disposition accuracy, measured by sustained findings rate across cases reviewed by compliance leadership or referred to state agencies.
• Typical tools: Claims adjudication platforms (commonly Facets or equivalent); data analytics and reporting (commonly MicroStrategy, SQL, or Tableau); coding reference systems (commonly encoder or CPC-standard tools).

• Base Salary Range: $58,000 to $82,000 annually, depending on seniority and certifications
• Bonus: Annual performance bonus of 5% to 10% of base salary, tied to audit output and recovery metrics
• Equity: Typically not offered at individual contributor level in managed care settings
• Health Benefits: Medical, dental, and vision coverage; employer contribution varies by plan
• PTO: 15 to 20 days annually, plus standard federal holidays
• Common Perks: Certification reimbursement, continuing education support, and hybrid or remote work options common in program integrity roles

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Reasonable accommodations are available to qualified individuals with disabilities throughout the application and employment process, in accordance with the Americans with Disabilities Act. Employment in this role is contingent on successful completion of a background check, which may include a review of criminal history consistent with applicable law. All applicants are considered without regard to race, color, religion, sex, national origin, age, disability, genetic information, or any other characteristic protected under federal, state, or local law. Candidates must be authorized to work in the United States.

The Claims Investigator owns the end-to-end resolution of product integrity, quality, damage, and count discrepancy claims by investigating root causes across transportation, plant, sales, and customer error categories, tracking deductions and DSO, and presenting data analysis and recommendations to the executive team. Working as a mediator between external parties and internal personnel, the Claims Investigator collaborates with sales teams to problem-solve customer accounts and supports improved payment outcomes across the business.

Key Responsibilities

• Investigate the root cause of claims across transportation, plant, sales, and customer error categories.
• Communicate company guidelines to appropriate parties.
• Acquire required documentation needed to determine liability quickly.
• Review legal documentation and determine if parties have provided required information to process a claim and fulfilled contractual requirements.
• Gather data and relay it to sales teams to problem-solve for customer accounts.
• Enter claims in SAP to be processed.
• Track data in Excel using pivot tables and extensive formulas.
• Keep detailed records and accounts of all claims, deductions, and DSO.
• Conduct comprehensive data analysis, find trends, and develop conclusions on claims.
• Present data analysis and recommendations to the executive team.
• Communicate with a sense of urgency to customers, carriers, and plants via phone and email.
• Work and learn new business areas as needed to improve customer payments.

Required Qualifications

• Bachelor's degree in Finance, Accounting, Business, Economics, or related field required.
• Prior experience handling customer accounts, including accounts receivable, claims, deductions, and DSO preferred.
• 2 or more years of experience processing claims, deductions, and customer DSO within designated time frames.
• Knowledge of cash application processes to assist with customer accounts preferred.
• Strong customer service skills with the ability to make decisions to mitigate losses quickly.
• Proficiency in SAP preferred.
• Advanced Excel skills, including pivot tables and complex formulas.
• Proficient in multiple computer systems and standard office applications.
• Excellent verbal and written communication skills.
• Highly organized with the ability to multitask and manage competing priorities.
• Self-driven with the ability to learn and adapt quickly.
• Determined to see projects through to completion, including those outside standard departmental scope.

Embedded within the customer service function, the Claims Investigator responds to and resolves claims and personal injury cases across all customer platforms, applying a first-time fix approach within agreed departmental SLAs while restoring customer faith and retaining customers cost-effectively. Working closely with support teams, PR agencies, and legal sources, the Claims Investigator monitors claims trends, provides feedback on recurrent issues, and ensures all contacts and resolutions are logged in real-time.

Core Functions

• Handle enquiries and concerns relating to claims and personal injury generated by customers across all platforms, remaining professional and empathetic at all times.
• Monitor and analyse trends in claims, providing feedback to the team leader on recurrent issues and suggesting preventative actions.
• Ensure communication across all channels meets departmental standards, using coaching feedback to continually develop performance.
• Answer all contacts within agreed departmental SLAs, applying a first-time fix approach.
• Take ownership of claims and injury cases using expert knowledge, providing satisfactory resolutions for customers.
• Build rapport with customers by identifying their needs and engaging with them effectively.
• Log all customer contact in the system in real-time as appropriate.
• Liaise with support teams, PR agencies, and legal sources as necessary to resolve issues, directing escalated contacts in line with the escalation policy.

Qualifications & Experience

• Retail, call centre, or customer service industry experience required.
• Experience within a similar customer service or claims-based role preferred.
• Excellent verbal and written communication skills.
• Flexible and open-minded approach to working, with strong multitasking and organisational skills.
• Ability to prioritise workload and maintain excellent administrative standards.
• Computer literate with experience using standard desktop applications such as Microsoft Office.
• Empathetic and open-minded with strong rapport-building skills.
• Ability to work effectively as part of a team and independently using own initiative.
• Strong work ethic with a desire to develop self and others.

Reporting to claims management, the Claims Investigator conducts face-to-face, telephone, and web-based interviews with policyholders, drivers, witnesses, police officers, and homeowners to progress claims toward satisfactory conclusions. Partnering with brokers, public bodies, and law enforcement agencies, the Claims Investigator represents the company in customer-facing dealings and provides technically accurate advice that upholds the company's image.

Primary Duties

• Investigate claims through interviewing various parties face-to-face, by telephone, or via web, including policyholders, drivers, witnesses, police officers, and homeowners.
• Attend incident scenes and undertake ad-hoc field intelligence enquiries.
• Liaise with public bodies, including law enforcement agencies.
• Obtain detailed accounts or signed statements in accordance with relevant legislation, procedures, and documentation to progress claims to a satisfactory conclusion.
• Represent the company in face-to-face dealings with customers and brokers, providing technically accurate advice and maintaining a positive company image.

Skills & Qualifications

• Industry-recognised qualification preferred, such as CII, Professional Investigators, or Accredited Counter Fraud Specialist.
• Experience handling, or knowledge of, EL, PL, PI, and Casualty claims.
• Sound knowledge of legal processes and recent experience in investigation and negotiation.
• Knowledge of motor and fraud claims benefits to the business.
• Experience in claims fraud investigation preferred.
• Awareness of the broker and affinity environment and the importance of such relationships.
• Excellent verbal and written communication skills.
• Valid full clean driving licence.

Sitting at the intersection of banking operations and regulatory compliance, the Claims Investigator investigates and resolves complex, large-dollar customer claims involving ATM, ACH, Bill Pay, and Zelle transactions in compliance with Regulation E, conducting comparative analysis to identify suspicious activity and prevent further loss. Operating across client-facing and back-office functions, the Claims Investigator prepares case documents for law enforcement, supports junior Claims Specialists, and ensures service level expectations are consistently met or exceeded.

Duties

• Investigate and resolve complex, large-dollar customer claims of error or unauthorised use involving ATM, ACH, Bill Pay, and Zelle in compliance with Regulation E.
• Communicate investigation results to clients and banking offices in a timely and professional manner.
• Research and identify suspicious activity through comparative analysis to determine whether activity is normal or requires proactive steps to prevent further loss.
• Perform advanced account research and problem resolution, including handling escalated calls and complaints.
• Prepare case documents for security and law enforcement agencies.
• Adhere to all banking regulations, policies, and procedures with strong working knowledge of applicable requirements.
• Deliver excellent customer service across all points of contact to meet or exceed service level expectations.
• Assist in the development of junior-level Claims Specialists as required.

Requirements

• High school diploma required; Associate's degree or related qualification preferred.
• 3 or more years of banking operations experience preferred.
• 2 or more years of call centre experience.
• Working knowledge of claims processing and banking regulations, including Regulation E.
• Solid analytical and problem-solving skills with attention to detail and accuracy.
• Strong verbal and written communication and interpersonal skills with a focus on customer service.

A key member of the investigations team, the Claims Investigator identifies, investigates, and evaluates instances of potential fraud, waste, and abuse by conducting interviews with patients, providers, and witnesses, performing statistical sampling of complex medical claims, and delivering findings as written summaries or presentations. Collaborating across clinical, legal, and compliance stakeholders, the Claims Investigator supports settlement determinations and contributes to special projects that strengthen programme integrity.

Functions

• Identify, investigate, analyse, and evaluate instances of potential fraud, waste, and abuse.
• Conduct interviews or correspond with patients, providers, witnesses, and other relevant parties to determine settlement, denial, or review.
• Analyse information gathered during investigation and report findings and recommendations as a written summary or presentation.
• Conduct statistical sampling of complex medical claims.
• Assist in drafting settlements.
• Participate in special projects as required.

Education & Experience

• Bachelor's degree in a related discipline, or equivalent combination of education, professional training, and work experience.
• Accredited Healthcare Fraud Investigator (AHFI), Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), Certified Forensic Interviewer (CFI), or Certified in Healthcare Compliance (CHC).
• 2 to 5 years of related investigative experience.
• Advanced or expert-level Excel skills.
• Excellent verbal and written communication skills.
• Strong listening and observation skills.
• Attention to detail and a high level of accuracy.
• Effective organisational and prioritisation skills with the ability to multitask.

Successful programme integrity and accurate case resolution depend on the Claims Investigator, who obtains written and recorded statements from witnesses, claimants, and involved parties, conducts site investigations, and preserves evidence while preparing written reports for supervisors and clients. Based within a team that includes former local, state, and federal agents, this role offers ongoing training and continued education to support professional advancement.

Accountabilities

• Obtain written or recorded statements from witnesses, claimants, and involved parties.
• Conduct neighbourhood canvasses and interviews.
• Perform site investigations.
• Obtain records, including court records, medical records, and police reports.
• Preserve evidence.
• Prepare written reports and provide updates to supervisors and clients.

Experience & Qualifications

• Bachelor's degree required; advanced degree or prior experience a plus.
• Excellent oral and written communication skills; foreign language proficiency a plus.
• Strong interpersonal skills.
• Ability to multitask, prioritise, and manage time effectively.
• Ability to work independently while handling an assigned case diary within a team-oriented environment.
• Willingness to learn and develop professionally.
• Personal registered and insured vehicle required, which must be maintained.

As the Claims Investigator, this role determines liability, negotiates settlements within assigned approval authority, and conducts professional investigations of routine to complex major incidents involving property damage and personal injury at utility sites. The legal and operations teams rely on this work to ensure the evidence chain of custody is maintained, case files are accurate, regulatory agencies receive required reports, and first responders across assigned business units are trained to act appropriately when incidents occur.

Role Responsibilities

• Determine liability and negotiate settlements within assigned approval authority, with input from management or legal counsel as directed.
• Ensure denial notifications or payments are made timely to claimants, that payment is received for damage claims, and pursue delinquent damage claim accounts.
• Mediate between customers and company contractors.
• Provide guidance and expertise to legal counsel for payment or denial determinations.
• Conduct professional investigations of routine to complex major incidents as subject matter expert.
• Control and investigate sites where damage or incidents occurred, ensuring evidence is secured and on-site safety is maintained.
• Maintain chain of custody of physical evidence.
• Perform research and complete documentation, including incident reports, in accordance with guidelines.
• Obtain witness statements and communicate with regulatory officials and agencies at local, state, and federal levels to provide reports and obtain records.
• Provide litigation support for assigned cases, including strategic planning, data gathering, and participation in mediations, settlement conferences, and court proceedings.
• Ensure case facts are effectively investigated and communicated, and that documentation and evidence are collected under the direction of legal counsel.
• Maintain well-developed and accurate case files.
• Collaborate with legal counsel on determination of appropriate reserve funding.
• Provide specialised training to assigned business units to ensure first responders take appropriate action when an incident occurs involving potential company liability.

Position Requirements

• High school diploma or equivalent required, post-secondary education or training in business, communications, engineering, or the gas/electric utility industry preferred.
• 1 to 3 years of combined gas/electric utility and claims-related work experience or equivalent required.
• Working knowledge of applicable federal and state utility laws and regulations, including NSEC, DOT, and state PUC requirements preferred.
• Ability to work under conditions involving exposure to noise, dirt, odours, confined areas, and variable weather.
• Availability to be on-call on a rotational basis required.
• Travel required for site investigations and court proceedings.
• Valid driver's licence with a good driving record and personal transportation required.

Claims Investigator administers indemnity payments, SROI filings, Benefit Notices, and void or stop-pay transactions for workers' compensation claimants with a 99% timeliness goal, acting in a fiduciary role on behalf of insureds in compliance with California WCAB rules, regulations, and statutes. The work directly supports claims examiners, medical providers, and return-to-work coordinators by ensuring payment accuracy, appropriate reserve levels, and timely case referrals throughout the life of each claim.

Day-to-Day Responsibilities

• Make indemnity payments to claimants, including lump sum and ongoing payments covering initial, final, and retroactive periods.
• Issue Benefit Notices as required for the start, change, and end of benefits.
• Issue Permanent Disability denials in applicable circumstances and notify the claims examiner accordingly.
• Transmit Second Report of Information (SROI) to the state as required.
• Gather and document information from medical providers on the disability status of claimants.
• Refer cases to the Return to Work Coordinator to gather and document information from insureds on return to work status and availability of modified or alternate duties.
• Follow up on return to work status through the coordinator until an offer is made or a final decision not to accommodate is reached.
• Refer cases as appropriate to management by setting an activity for review.
• Maintain professional client relationships.
• Notify the examiner on time on cases with indemnity payments regarding the need for appropriate reserves.
• Coordinate and process void, stop pay, and reissue of indemnity payments.
• Assist technical and operations teams with other duties as needed.

Minimum Qualifications

• Bachelor's degree from an accredited college or university preferred.
• Experienced Examiner Certification required within the first year, including 120 hours of classroom training, with 30 hours of continuing education every two years to maintain certification.
• 2 or more years of related administrative office work experience.
• Knowledge of workers' compensation principles and policies preferred.
• California Workers' Compensation Appeals Board (WCAB) regulatory compliance experience required.
• Proficient in Microsoft Office software and standard PC applications.
• Strong written and verbal communication skills with attention to detail and adherence to deadline structures.
• Ability to work both independently and collaboratively with all levels of staff.

The Claims Investigator shapes the resolution of municipal liability matters by developing and executing investigative plans, interviewing witnesses, performing on-site inspections, and preparing written summaries with settlement recommendations for approval by the Claims Manager or supervising attorney. Reporting to legal practice group leadership and collaborating with insurance companies, attorneys, government agencies, and internal departments, the Claims Investigator manages a caseload to achieve timely claim resolution while limiting organisational liability.

What You'll Do

• Develop and execute investigative plans to gather information, including witnesses, electronic data, and physical evidence, to assess the validity of a claim.
• Correspond and work with individuals, insurance companies, attorneys, government agencies, and inter-departmental teams to prioritise, manage, and investigate claims.
• Locate and schedule appointments with witnesses, including employees, medical professionals, and other individuals, for interviews.
• Employ screening and investigative techniques such as logical deduction and critical thinking.
• Answer claims-related calls, letters, texts, and emails on time, and regularly update claimants and other concerned parties.
• Maintain case files using case management software.
• Manage workload to achieve timely and efficient resolution of claims while limiting organisational liability.
• Develop relationships with key members of legal practice groups and other internal departments, boards, and agencies.
• Prepare written summaries of claim investigations and preliminary settlement documents with recommendations for disposition for approval by the Claims Manager or supervising attorney.
• Present case studies to team members identifying issues, challenges, and best practices for determining appropriate resolution.
• Use a variety of investigative resource tools, including state and local codes, Westlaw, and specialised investigation tools.
• Operate the document management system with proficiency.

Background & Experience

• Associate's degree and 10 or more years of experience in insurance or risk management, or high school diploma and 10 or more years of equivalent experience.
• Insurance Adjuster Licence required.
• 5 or more years of progressive administrative or risk management investigative experience, or equivalent combination of education, training, and experience.
• Ability to compile, organise, prepare, and maintain records, reports, and information in accordance with departmental and governmental regulations.
• Valid driver's licence required.

Reporting to a claims manager or supervisor, the Claims Investigator analyses and validates claim data elements, processes non-institutional claim types, and adjudicates pended claims in adherence to regulatory legislation, contractual pricing agreements, and Medi-Cal guidelines, including ICD-10 and CPT billing code sets. Partnering with staff and providers at all levels, the Claims Investigator maintains established quality and production standards while developing effective working relationships to support accurate and compliant claims adjudication.

Key Deliverables

• Perform thorough review of pended claims for billing errors and questionable billing practices, including duplicate billing and unbundling of services.
• Process non-institutional claim types.
• Correct system-generated errors manually before final claims adjudication.
• Process claims based on contractual agreements, pricing agreements, applicable regulatory legislation, and claims processing guidelines and policies.
• Analyse and validate Medi-Cal pricing, research, adjust, and adjudicate claims, and review services for accurate charges using current billing code sets including ICD-10 and CPT codes.
• Validate eligibility and other possible health insurance coverage on the claim.
• Alert manager or supervisor of more complex issues as they arise.
• Process claim exception reports as assigned.
• Meet and maintain established quality and production standards.
• Work independently and as part of a team while providing excellent customer service.
• Develop and maintain effective working relationships with all levels of staff and providers.

Knowledge, Skills & Abilities

• 1 or more years of experience processing online medical claims in a managed care, PPO, indemnity, or billing environment required.
• Experience processing Medi-Cal claims preferred.
• Knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPC), and ICD-10 codes.
• Knowledge of industry pricing methodologies, including Resource-based Relative Value Scale and Medicare/Medi-Cal Fee Schedule.
• Understanding of medical terminology, benefit interpretation, and administration.
• Knowledge of Medi-Cal guidelines and regulations.
• Proficient in the Facets Processing System or equivalent claims adjudication platform preferred.
• Proficient in Microsoft Office, including Word, Excel, and PowerPoint.
• Ability to handle multiple tasks and meet deadlines.

Claims Investigator delivers accurate investigation and resolution of freight claims by maintaining a claims tracking database from initial filing through resolution, managing a claims portal to proactively identify chargebacks, and coordinating documentation with QA and cross-functional teams. The work directly supports customer satisfaction and financial accuracy by generating credits and bill-outs, verifying accruals and rebates, and maintaining a quality incident tracker from notification to completion.

Scope of Work

• Investigate the validity of freight claims and assemble required documentation.
• Maintain a database for claims tracking from initial filing through resolution.
• Maintain electronic freight claim files and documentation in an organised manner.
• Manage the claims portal to proactively identify claims prior to becoming chargebacks.
• Communicate with customers on chargebacks and resolutions.
• Maintain working relationships with customers, carriers, and colleagues to facilitate claims processing and investigations.
• Identify, analyse, and communicate claims trends to appropriate cross-functional teams.
• Investigate short pay discrepancies, complete required dispute processes, and acquire appropriate back-up documentation including bills of lading and cycle counts.
• Investigate damage claims, complete appropriate paperwork, track submitted claims, and follow up as needed.
• Verify accruals and rebates and assign to the correct general ledger.
• Collaborate with QA on proper documentation needed for claims.
• Provide all necessary documentation to cross-functional teams for resolutions.
• Respond to customer inquiries on freight claim issues.
• Enter cases and return merchandise authorisations into the claims management system for returns tracking.
• Generate credits and bill-outs for customers.
• Enter and follow up on quality incident complaints and inquiries for national accounts, providing resolutions to customers.
• Maintain the quality incident tracker from initial notification to completion.

Professional Experience

• High school diploma required; college courses or degree in finance or business a plus.
• Minimum 2 years of related experience in claims or a related field.
• 1 or more years of experience in general office or accounting positions.
• Experience in customer service and the transportation industry preferred.
• Intermediate proficiency in Microsoft Word, Excel, and Outlook.
• Strong verbal and written communication skills, including proper business email and letter format, and the ability to communicate effectively with different levels of management.
• Strong attention to detail.
• Ability to solve practical problems and manage a variety of variables with limited standardisation.
• Ability to multitask, prioritise, and work under pressure within time constraints.
• Proactive, can-do attitude with a willingness to assist others and continuously improve processes.

Embedded within the Law Department across Litigation, Regulatory, Contract, and Corporate Services functions, the Claims Investigator investigates and resolves third-party property damage, bodily injury, and business interruption claims by conducting on-site and field investigations, performing comparative data analysis for trending and lessons learned, and providing litigation support and training to attorneys and internal clients. Working closely with contractors, insurance carriers, and multiple levels of management and union personnel, the Claims Investigator must travel at least 25% of the time and be available on-call on a rotating basis to respond to emergencies.

Technical Responsibilities

• Investigate, negotiate, and settle third-party property damage and personal injury claims.
• Investigate and report on incidents that may lead to litigation and review tender cases involving contractors and insurance carriers.
• Conduct interviews with employees and third parties to investigate claims and incidents.
• Conduct claims data analysis for trending and lessons learned, and present findings to business partners.
• Perform onsite, field, and internal investigations to determine root causes, impacts, and effects of claims and incidents.
• Research and collect evidence and facts to support investigations of claims and incidents.
• Provide investigative support for collection cases.
• Review internal and external records, files, and documents related to incident investigations, liability and damage evaluation, and claims negotiation and settlements.
• Provide litigation support, consultation, and training to attorneys and internal clients.

Education & Experience

• Bachelor's degree or equivalent experience.
• Certified Insurance Claims Investigator (CICI) and California Claims Adjuster license preferred.
• 2 to 4 years of experience handling claims investigations or related experience; utility industry experience preferred.
• Experience in investigating and administering bodily injury, property damage, and insurance claims and litigation.
• Knowledge of insurance claims, casualty claims adjustment, claims management, investigations, and settlements.
• Knowledge of tort and contract law and medical terminology.
• Demonstrated ability to engage multiple levels of management, leadership, personnel, and unions.
• Strong leadership, organisational, interpersonal, communication, and presentation skills.
• Proficient in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
• Ability to travel at least 25% of the time and be on-call on a rotating basis.

The Claims Investigator refines the accuracy and integrity of provider and member claims data by reviewing and analysing behavioural health claims across inpatient, residential, partial hospitalisation, and outpatient settings, comparing billing submissions against CPT, HCPCS, DRG, ICD-10, and Revenue Codes to identify inappropriate submissions and document findings in detailed written reports for management and court proceedings. Reporting to compliance and programme leadership and interfacing directly with providers, the Claims Investigator maintains current knowledge of federal and state coding regulations and delivers professional provider education to support ongoing compliance.

Areas of Ownership

• Review and analyse provider and facility behavioural health claims, including inpatient, residential, partial hospitalisation, intensive outpatient, and outpatient, alongside associated medical records for coding appropriateness and documentation requirements.
• Conduct background research on providers and associated partners.
• Collect, organise, analyse, and disseminate significant amounts of information with attention to detail and accuracy.
• Compare information submitted on claims to determine the amount and nature of billable services.
• Identify trends and concerns related to potentially inappropriate claim submissions by providers or facilities.
• Document findings for each claim line with appropriate payment calculations in a findings spreadsheet.
• Summarise findings in a written report for management and, where applicable, court proceedings.
• Maintain current knowledge of coding guidelines and relevant federal and state regulations.
• Interface with providers regarding compliance with all federal, state, and contractual regulations and obligations.
• Provide clear, concise, and professional provider education in verbal and written format.

Minimum Qualifications

• Bachelor's degree in Healthcare, Business, Computer Science, Mathematics, or a related field, or equivalent experience; Master's degree preferred.
• Certified Professional Coder (CPC) or equivalent required; additional certifications such as Accredited Healthcare Fraud Investigator, Certified Fraud Examiner, or Certified in Healthcare Compliance preferred.
• 2 or more years of healthcare claims or reimbursement experience.
• Experience in healthcare, fraud investigations, managed care, or a related field.
• Experience with medical records review, claims analysis, and healthcare claim adjudication standards and procedures.
• Experience with outpatient and facility behavioural health providers preferred.
• Proficiency in all healthcare coding systems, including CPT, HCPCS, DRG, ICD-10, and Revenue Codes.
• Knowledge of medical policy and the ability to articulate health information clearly.
• Proficient in Microsoft Excel and other Microsoft Office products.
• Experience with SQL, Tableau, or fraud analytics software preferred.
• Strong analytical and investigative skills with an intuitive ability to identify investigational leads related to fraud, waste, or abuse.
• Excellent oral and written communication skills across all levels of the organisation.
• Ability to work independently and as part of a team while managing multiple and conflicting priorities.

Claims Investigator oversees programme integrity monitoring through fraud and abuse investigations, post-payment audits of Medicaid and state-funded providers, and implementation of provider corrective actions, analysing data from claims, authorisations, credentialing records, incarceration records, and incident reports to inform disposition recommendations presented to senior compliance leadership and relevant oversight bodies. The Special Investigations Unit, Senior Management, Chief Compliance Officer, and General Counsel rely on this work to ensure overpayments and irregularities are identified, documented, and resolved in accordance with state and federal Medicaid laws and contractual terms.

Strategic Responsibilities

• Review allegations, conduct preliminary investigations, and make disposition recommendations using independent judgment.
• Develop audit and investigation plans and tools based on alleged non-compliance and data analytics.
• Request and collect medical records, personnel records, policies, procedures, compliance plans, and other documents from providers based on audit and investigation plans.
• Systematically collect, document, and store evidence with accuracy.
• Conduct post-payment audits of Medicaid and state-funded providers to ensure services are rendered in accordance with established state and federal rules, regulations, and contractual terms.
• Identify inappropriate billing and overpayments.
• Conduct interviews with provider employees, former employees, service recipients, and other witnesses.
• Document allegations, investigative activities, and findings in a detailed audit and investigation report.
• Track allegations of fraud, waste, and abuse in a case management system from referral to final disposition.
• Research clinical policies, administrative code, and federal and state laws to assess for non-compliance.
• Analyse data from multiple sources, including claims, authorisations, credentialing, grievances, prior audits, incarceration records, and incident reports, to inform decision-making.
• Present audit and investigation findings and disposition recommendations to senior compliance leadership and relevant oversight bodies.
• Conduct and participate in investigation planning meetings with the investigation team.
• Educate providers on errors identified during the audit and investigation process and provide technical assistance where a full investigation is not warranted.
• Prepare for and participate in provider appeal processes and court hearings to explain and defend audit findings.

Technical Qualifications

• Bachelor's degree in healthcare compliance, analytics, public administration, auditing, criminal justice, or a related field required.
• Fraud certification from ACFE, NHCAA, AAPC, or equivalent coding certificate preferred; National Certified Investigator and Inspector Training (NCIT) preferred.
• 3 or more years of post-degree experience in healthcare compliance, regulatory analysis, auditing, or investigations.
• Knowledge of state and federal Medicaid laws, criminal and civil fraud laws, regulations, and various Medicaid programme requirements.
• Knowledge of claims adjudication standards, procedures, and investigative methods.
• Knowledge of MCO functions, including prior authorisation, utilisation review, grievance management, and provider credentialing and monitoring.
• Knowledge of Medicare, Medicaid, and behavioural health programmes and service benefit plans.
• Proficient in Microsoft Office, with strong Excel skills required.
• Experience with data analytics platforms such as MicroStrategy preferred.
• Strong verbal and written communication skills, including the ability to write clear, accurate, and concise rationale in support of findings.
• Ability to interpret contractual agreements, business-oriented statistics, and medical and administrative records.
• Analytical skills with the ability to identify resources, gather evidence, analyse raw data, and generate reports.
• Ability to manage time, prioritise work, and apply problem-solving approaches effectively.
• High degree of integrity and confidentiality in handling personal and sensitive information.