Fraud Investigation Analyst

Zelis Healthcare, LLC
United States, Massachusetts, Boston
May 07, 2025
At Zelis, we Get Stuff Done. So, let's get to it! A Little About Us Zelis is modernizing the healthcare financial experience for all by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts-driving real, measurable results for clients. A Little About You You bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are. Position Overview The Fraud Investigation Analyst, Enterprise Fraud, will contribute significantly to safeguarding Zelis against fraudulent activities by conducting comprehensive reviews of all internal and external fraud monitoring alerts, performing fraud investigations, and thoroughly documenting all findings and outcomes. In this role, you will be expected to provide timely updates on observed fraud trends and emerging patterns to assist Enterprise Fraud in developing fraud strategies and suspicious activity monitoring. Collaboration is key in this position, as you will work closely with various areas within Zelis, including Payments Optimization, Price Optimization, Insights & Empowerment, Compliance, and People & Culture. Your ability to combine an extensive set of investigative skills with your knowledge of Zelis and our products, services, and clients, will be put to the test on a daily basis. This role requires keen analytical skills, a passion for preventing wrong-doing, and a fervent curiosity to investigate in order to support Enterprise Fraud in prevention, detection, reporting, and monetary recovery related to financial fraud and healthcare fraud, waste, and abuse. What You'll Do Perform reviews and detailed link analysis utilizing various tools and reports to identify internal or external fraudulent activity, including potential Fraud, Waste, and Abuse (FWA), across all Zelis business units and functions. Initiate fraud investigations and handle all aspects, including detailed documentation, analysis, research, summaries and case management within the appropriate tracking systems to ensure information is accurate and timely. Examine public record databases, open-source records, statements, invoices, correspondence, device data and other records pertaining to the transactions, events, financial crimes, or other incidents under investigation. Develop working relationships and communicate with federal, state, and local officials, and other organizations and individuals related to investigations for the purpose of gathering facts, obtaining statements, learning sequences of events, obtaining explanations, and otherwise advancing investigative objectives. Through regular participation in industry groups and associations, maintain up-to-date knowledge and awareness of best practices in fraud detection and prevention, investigative fraud techniques, fraud industry trends, and significant fraud events. Identify and recommend policy, procedure and system changes to enhance investigative outcomes and performance. Contribute to the creation and updating of Enterprise Fraud documentation (e.g. Standard Operating Procedures) and data repositories (e.g. Known Fraud Data Negative List.) On limited occasions, conduct investigations after hours or on weekends for escalated or high-priority Fraud events. What You'll Bring to Zelis Bachelor's degree is required, preferably in Criminal Justice, Finance, Accounting, or Business Administration. 4+ years of experience related to fraud prevention, financial services, risk management, or compliance, preferably in the healthcare industry. Professional industry certification as a Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Health Care Anti-Fraud Associate (HCAFA), Certified Financial Crimes Investigator (CFCI), or Certified Financial Crime Specialist (CFCS), preferred. Proficient knowledge of Microsoft Excel, Word, PowerPoint, and case management or case review applications. Strong logical, analytical, and critical thinking skills, paired with a willingness to solve problems using creativity and innovation. Ability to effectively determine fraud risk while remaining objective and separating facts from opinions. Demonstrate high ethical standards that drive initiative, excellent follow-through, and persistence in locating and securing needed information. Effective organizational, communication, and interpersonal skills with a demonstrated ability to foster collaborative work partnerships with individuals at all levels. Ability to multi-task, adapt quickly to changing priorities, and operate effectively across geographic and functional boundaries to meet tight deadlines. Location and Workplace Flexibility We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all. Accessibility Support We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com. Disclaimer We are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law. The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.