Job Description

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nations leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to hear you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at  

Summary
The Investigator plays a critical role in identifying and preventing fraud, waste, and abuse across the AmeriHealth Caritas Family of Companies (ACFC). This position ensures compliance with investigative regulations, conducts thorough analyses to detect fraudulent activity, and collaborates with law enforcement, regulatory agencies, and internal teams to uphold organizational integrity.

Responsibilities

• Lead investigations into potential fraud, waste, and abuse, ensuring accuracy, efficiency, and compliance with legal and regulatory standards.
• Conduct in-depth interviews with witnesses, providers, and other relevant parties, gathering evidence in accordance with criminal and civil legal guidelines.
• Analyze claims, billing data, and emerging patterns to proactively identify fraudulent activity, leveraging fraud detection software and investigative tools.
• Develop and submit comprehensive investigative reports, clearly interpreting and communicating findings.
• Represent ACFC in discussions with providers, law enforcement, and regulatory bodies, ensuring professional engagement and resolution.
• Maintain confidentiality and uphold the highest ethical standards when handling sensitive information.
• Build and maintain strong working relationships with law enforcement agencies, compliance teams, and internal stakeholders to support investigations.

Education & Experience

• Associate’s degree required (Bachelor’s preferred).
• Minimum of 3–5 years of experience conducting healthcare fraud investigations and collaborating with state, federal, and local law enforcement agencies.
• Strong knowledge of Medicaid, Medicare, and fraud-related regulatory statutes required.
• Proficiency in Microsoft Excel for data analysis and investigative documentation, and clear, effective communication of findings through verbal and written reports.
• Expertise in investigative procedures, claims adjudication, clinical investigations, and healthcare fraud detection techniques.
• Valid driver’s license and proof of active car insurance required for investigative travel.
• Experience in law enforcement, Special Investigations Unit (SIU), or regulatory compliance.
• Advanced understanding of fraud prevention strategies, regulatory enforcement practices, and data-driven investigative tools.
• Proficiency in investigative software and emerging fraud detection technologies.
• Strong analytical, problem-solving, and decision-making skills to assess risk and detect fraud.
• Ability to work independently, manage multiple priorities, and handle high-volume assignments with minimal supervision.
• High ethical integrity and confidentiality in handling sensitive investigative matters.
• Attention to detail, adaptability, and a proactive mindset for fraud detection and prevention.
• Effective collaboration with internal teams, law enforcement, and regulatory agencies.
• Ability to prioritize tasks effectively in a fast-paced, high-stakes environment.
  
   

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve. We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

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