Medicaid Investigator – Northeast (NE ZPIC)

Job Summary:
Purisolve, Inc. is seeking a qualified Medicaid Investigator to support fraud and compliance investigations under the Northeast Unified Program Integrity Contractor (UPIC) contract. This position focuses exclusively on Medicaid-related investigations in Northeast area, addressing potential fraud, waste, and abuse in the region’s healthcare delivery system.

The ideal candidate has experience conducting investigations in Medicaid environments—particularly for or with CMS contractors—and demonstrates strong interviewing, analytical, and written communication skills. This is a mission-critical role that contributes directly to safeguarding taxpayer-funded healthcare programs.

Responsibilities:

• Conduct field-based investigations related to Medicaid fraud, abuse, or non-compliance, aligned with UPIC protocols and state-specific Medicaid rules.
• Interview healthcare providers, beneficiaries, and witnesses to gather key case evidence.
• Analyze Medicaid claims, billing patterns, and supporting documentation to identify irregularities or suspicious activity.
• Prepare detailed investigative reports suitable for law enforcement referrals, overpayment recovery, or administrative actions.
• Collaborate with law enforcement entities, state Medicaid agencies, and CMS stakeholders.
• Maintain and manage documentation and case files in compliance with CMS and contractual standards.
• Represent Purisolve with professionalism and discretion during field engagements and stakeholder communications.

Minimum Qualifications:

• 3+ years of investigative experience focused on Medicaid, Medicare, or healthcare program integrity.
• Demonstrated proficiency in interviewing, evidence gathering, and report drafting.
• Ability to work in a high-paced environment handling numerous concurrent investigations.
• Strong working knowledge of Medicaid policies, fraud typologies, and regulatory enforcement.
• Excellent written communication and attention to detail.
• Proficiency in Microsoft Office applications (Word, Excel, Outlook).
• Residence in Northeastern US and willingness to travel occasionally for site visits.

Preferred Qualifications:

• Prior experience supporting ZPIC, UPIC, or SIU (Special Investigations Unit) contracts.
• Familiarity with Medicaid rules and provider structures.
• Certified Fraud Examiner (CFE) or other fraud-related credentials.
• Experience using electronic case management and claims analytics tools.

Salary & Work Structure:

• Salary Target: $70,000 (subject to qualifications and regional cost-of-living adjustments)
• Work Type: Remote/Work from home with field-based investigations in the northeastern, US
• Schedule: Full time, Monday – Friday (standard business hours)

Education:
We will consider any of the following:

• High school degree with seven (7) years of experience
• Associate's degree with five (5) years of experience
• Bachelor's degree with two (3) experience
• Master's degree with one (1) year experience

About Our Company:
Purisolve, Inc. is a professional services consulting firm specializing in client solutions to improve information management, data analytics, and business intelligence. We are committed to helping our clients become strategic data-driven organizations to increase revenues, reduce costs, or improve efficiencies.

Our firm name, Purisolve, was derived by combining two words: "purity" and "solutions". The word "purity" represents unblemished integrity, including professionalism and work ethic, which is a core value of our firm. The word "solutions" is a simple term that represents innovation and customer-focused results for solving problems.

Purisolve was founded in 2007, and has had steady growth in both revenue and employees. This growth has been driven by our commitment to client service and the value we deliver.

Our team is composed of highly skilled professionals who are passionate about making a difference in the communities we serve. Through various social responsibility initiatives, we strive to give back and create a positive impact on society. Joining Purisolve means becoming part of a forward-thinking organization that values its employees. We support a healthy work-life balance and are dedicated to helping team members achieve their full potential.

Disclaimer:
Please note that initial application screenings may be conducted using AI-based tools. These tools are employed to assist in efficiently processing and evaluating applications, ensuring that all candidates are considered fairly. The AI tools are designed to assess qualifications based on the information provided in your application and resume. However, all final hiring decisions are made by our executive leadership team, ensuring a thorough and personalized evaluation of each candidate. By submitting your application, you acknowledge and agree to this process.

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