council-capital - Healthcare Fraud Investigator

Nashville, Tennessee, United States+ Equity3mo ago

Remote Mid NA Fraud Examiner Auditor Case Management CPC Close Documentation

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). • 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. • Council Capital and our portfolio companies are committed to building high-performing teams by hiring the best talent—period. • We believe in putting the right people in the right seats, regardless of background, and we’re always looking for individuals who bring fresh thinking, grit, and a drive to make a difference. • Thank you for considering a role with one of our companies. We’re excited to learn more about you.

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.