Fraud, Waste & Abuse Investigator

Detego Health; Omaha (NE); Hybrid; USD 34,000 - 41,000; Full time

Benefits offered by this job

401(k) matching

Health insurance

Dental insurance

Paid time off

Job summary

Detego Health in Omaha is seeking a Fraud, Waste & Abuse (FWA) Investigator to identify and resolve suspected fraud, waste, abuse, and overpayments. You will develop case files, analyze claims and evidence, and report financial impact with clear narratives for stakeholders.

You'll collaborate with Claims, Payment Integrity, Compliance, Legal, COB, Subrogation, and Client Services to prevent loss and improve processes.

Qualifications

• Bachelor’s degree in Criminal Justice, Healthcare Administration, Business, Finance, Nursing, Healthcare Operations, or a related field.
• 3+ years in healthcare claims, payment integrity, SIU, investigations, audit, or compliance.
• Knowledge of claims adjudication, provider billing practices, reimbursement methods, and documentation standards.
• Experience with data analysis tools and case-tracking systems; strong writing skills.
• Certification such as CFE, AHFI, CPC, or related credential is a plus.

Responsibilities

• Investigate suspected fraud, waste, abuse, and overpayments in provider or member claims.
• Review claims, medical records, enrollment and payment data to build evidence.
• Conduct interviews and prepare summaries, chronologies, and reports.
• Present findings to the FWA Manager, Compliance, Legal, and stakeholders.
• Collaborate with Claims, Payment Integrity, Compliance, Legal, COB, and Client Services.

Skills

Investigative mindset

Analytical thinking

Strong writing skills

Discretion & confidentiality

Communications

Education

Bachelor’s degree in Criminal Justice, Healthcare Administration, Business, Finance, Nursing, Healthcare Operations, or related field

Tools

Claims platforms

Case tracking systems

Audit documentation systems

Job description

Company OverviewDetego Health's mission is to connect real-life needs with innovative product design, delivering affordable, approachable health care benefits that feel personal, while deeply understanding our members and partners to improve lives and redefine access to health care.We're looking for passionate people who want to make a difference and help us redefine access to health care for individuals and small businesses by delivering certainty, connection and significance where others won’t.Ready to build something great together? Join a team that values growth, collaboration and the unique perspective you bring.Position SummaryThe Fraud, Waste & Abuse (FWA) Investigator identifies, investigates, and resolves suspected fraud, waste, abuse, overpayments, and billing irregularities. This role supports the enterprise FWA program through case development, claims and evidence analysis, financial impact assessment, and clear investigative reporting.Key ResponsibilitiesInvestigationsInvestigate suspected fraud, waste, abuse, overpayments, and billing irregularities involving providers, members, vendors, or internal processesEvaluate referrals from audits, data analytics, claims review, complaints, and employee reportsReview claims, medical records, provider documentation, enrollment and payment records, plan materials, and correspondence to build a complete, defensible evidence fileConduct interviews or obtain statements when appropriate and authorizedCase ResolutionIdentify patterns and indicators that call for escalation, recovery, corrective action, or closureCalculate financial impact, including overpayments, recoveries, savings, and exposureRecommend case disposition, recovery, education, or process improvementsDocumentation & ReportingMaintain detailed case files from intake through final dispositionPrepare investigative summaries, chronologies, evidence logs, and final reports that document findings, rationale, and next stepsPresent findings to the FWA Manager, Compliance, Legal, Payment Integrity, and other stakeholdersCollaboration & PreventionPartner with Claims, Appeals, Payment Integrity, Compliance, Legal, COB, Subrogation, Provider Relations, and Client ServicesSupport fraud prevention through employee education, referral procedures, monitoring projects, and corrective action follow-upSupport regulatory, client, audit, or law enforcement matters as directed by leadershipCompany OverviewDetego Health's mission is to connect real-life needs with innovative product design, delivering affordable, approachable health care benefits that feel personal, while deeply understanding our members and partners to improve lives and redefine access to health care.We're looking for passionate people who want to make a difference and help us redefine access to health care for individuals and small businesses by delivering certainty, connection and significance where others won’t.Ready to build something great together? Join a team that values growth, collaboration and the unique perspective you bring.Position SummaryThe Fraud, Waste & Abuse (FWA) Investigator identifies, investigates, and resolves suspected fraud, waste, abuse, overpayments, and billing irregularities. This role supports the enterprise FWA program through case development, claims and evidence analysis, financial impact assessment, and clear investigative reporting.Key ResponsibilitiesInvestigationsInvestigate suspected fraud, waste, abuse, overpayments, and billing irregularities involving providers, members, vendors, or internal processesEvaluate referrals from audits, data analytics, claims review, complaints, and employee reportsReview claims, medical records, provider documentation, enrollment and payment records, plan materials, and correspondence to build a complete, defensible evidence fileConduct interviews or obtain statements when appropriate and authorizedCase ResolutionIdentify patterns and indicators that call for escalation, recovery, corrective action, or closureCalculate financial impact, including overpayments, recoveries, savings, and exposureRecommend case disposition, recovery, education, or process improvementsDocumentation & ReportingMaintain detailed case files from intake through final dispositionPrepare investigative summaries, chronologies, evidence logs, and final reports that document findings, rationale, and next stepsPresent findings to the FWA Manager, Compliance, Legal, Payment Integrity, and other stakeholdersCollaboration & PreventionPartner with Claims, Appeals, Payment Integrity, Compliance, Legal, COB, Subrogation, Provider Relations, and Client ServicesSupport fraud prevention through employee education, referral procedures, monitoring projects, and corrective action follow-upSupport regulatory, client, audit, or law enforcement matters as directed by leadershipQualificationsBachelor’s degree in Criminal Justice, Healthcare Administration, Business, Finance, Nursing, Healthcare Operations, or a related field3+ years in healthcare claims, payment integrity, SIU, investigations, audit, or complianceKnowledge of claims adjudication, provider billing practices, reimbursement methods, and documentation standardsExperience reviewing claims data, medical records, plan provisions, provider records, and payment documentationStrong writing skills for clear investigative documentationCertified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or related healthcare compliance credentialExperience at a self-funded health plan or third-party administrator (TPA)Experience with data analysis tools, claims platforms, case tracking systems, or audit documentation systemsKey SkillsStrong investigative judgment, critical thinking, and analytical abilityManages multiple cases while meeting deadlines and documentation standardsDiscretion and strict confidentiality with sensitive informationCommunicates findings clearly to leadership and cross-functional partnersCompensation & BenefitsCompensation: 25-30Work Location: Omaha-based employees will work in-office or on a hybrid schedule.Benefits: 401(k), 401(k) matching, Dental insurance, Employee assistance program, Health insurance, Health savings account, Life insurance, Paid time off, Vision insuranceDetego Health is an equal opportunity employer