Lead Fraud Investigator

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary BASIC FUNCTION HCSC is looking for a dynamic individual to join its Fraud Investigations team! This position will be responsible for identifying, developing and managing complex, high-impact healthcare fraud investigations resulting in criminal and/or civil prosecution and the misuse of claims, billing, or improper payments. May also be responsible for establishing and maintaining close liaison (as indicated in plan design) with departments/personnel and law enforcement representatives to further the department’s investigation efforts and referral for prosecution of healthcare fraud cases. Will be reviewing transactions, claims, or reports to detect fraud and prepare detailed reports for management, attorneys, or law enforcement and possibly testifying in court. Incumbent conducts complex, large-scale investigations and mentor junior-level investigators. expertise in data analysis tools (e.g., advanced Excel), investigative proficiency, and strong communication skills NOTE: this role is hybrid/flex and requires in-office visibility three days per week, working from home the other two days. Relocation is NOT offered; sponsorship will NOT be extended either now or in the future. #LI-TP1 #LI-hybrid JOB REQUIREMENTS Bachelor’s Degree. Seven (7) years’ fraud investigative experience OR 7 years of direct law enforcement experience (local, state, or federal). Experience directing complex fraud investigations which result in criminal or civil prosecutions. Aptitude with planning and conducting interviews which develop significant information in furtherance of complex fraud, waste, and abuse investigations. Familiarity with state and federal laws apps. Expertise in data analysis tools, investigative proficiency, and strong communication skills. Proficiency with MS Office (Word, Excel, PowerPoint) as well as Workday. PREFERRED REQUIREMENTS Certified Professional Coder (CPC). Certified Fraud Examiner (CFE). Accredited Health Care Fraud Investigator. Exceptional ability to identify fraud, waste and abuse trends and work with advanced analytics in identifying emerging schemes and trends. Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process! Pay Transparency Statement: At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. HCSC Employment Statement: We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Base Pay Range $61,500.00 - $136,100.00 Exact compensation may vary based on skills, experience, and location. Join our talent community and receive the latest HCSC news, content, and be first in line for new job opportunities. Join our Talent Community. For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities. Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren’t afraid to make innovative contributions. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Learn more about HCSC, our commitment to our members and the opportunity you’ll have to improve health care delivery in an open, collaborative environment. HCSC is committed to diversity in the workplace and to providing equal opportunity to employees and applicants. If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations. Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "candidate home" to view your job submissions. Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas, Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, and Independent Licensee of the Blue Cross and Blue Shield Association © Copyright 2025 Health Care Service Corporation. All Rights Reserved. Apply To This Job