Healthcare Fraud Investigator

About Council Capital and Alivia Analytics

Council Capital, a Nashville-based private equity firm specializing in healthcare, manages over $350 million in committed capital. The firm invests in lower middle market healthcare companies with enterprise values from $10 million to $100 million, supporting founders and leadership through the Council Model. This model combines guidance from an experienced CEO Council, insights from Strategic Healthcare Investors, and internal growth facilitation via a Value Creation Team.

Alivia Analytics, part of Council Capital's portfolio, offers a payment integrity platform that identifies and recovers improper payments for healthcare payers. It uses analytics alongside expert reviews to detect fraud, waste, and abuse in Medicare, Medicaid, Commercial, and FEP plans, generating substantial financial return for clients. The company is expanding its service team to meet growing client demand.

Position Overview

The Healthcare Fraud Investigator's role involves sourcing and managing improper payment leads from initial identification to recovery. You will handle a live caseload, collaborating with payer clients, coders, and customer success teams. This role does not include supervisory duties. Ideal candidates come from healthcare payer/vendor roles or have investigative experience paired with deep knowledge of healthcare claims.

Key Responsibilities

• Qualify and identify over 100% of the budgeted leads monthly, approximately 15 leads per month.
• Achieve a minimum 50% acceptance rate of leads by clients.
• Manage an active caseload of 20 to 30 cases monthly from initiation to resolution.
• Close 90% of cases within four to five months.
• Convert identified case value to realized recoveries, attaining 100% of revenue targets, equating to about 45% conversion rate.
• Maintain a 95% first-time acceptance rate for submitted documentation to customers.
• Ensure zero payer complaints and reduce provider friction during all interactions.
• Operate proficiently across Medicare, Medicaid, Commercial, and FEP lines of business.

Required Qualifications

• At least two years of experience as an Investigator or Auditor within a healthcare payer or vendor setting focusing on healthcare claims.
• Knowledge of multiple insurance lines including Medicare, Medicaid, Commercial, and FEP.
• Familiarity with auditing software, claims systems, and case management tools.
• Proven experience managing the complete investigation cycle from lead identification to revenue recovery.
• Strong analytical skills coupled with negotiation capabilities to secure defensible, advantageous outcomes.
• Must reside in the U.S. with authorized work eligibility, given the protected health information environment.

Preferred Credentials

• Certified Fraud Examiner (CFE).
• Certified Professional Coder (CPC).
• Accredited Health Care Fraud Investigator (AHFI).
• Certified Anti-Fraud Professional (CAFP).
• Based in Eastern or Central U.S. time zones.

Culture and Commitment

Council Capital and its affiliates prioritize building high-performing teams with diverse talent and innovative thinking. They seek individuals driven by impact and resilience, regardless of background.