Job Summary:

The Manager, Healthcare Forensics plays a critical role in supporting healthcare organizations through complex regulatory environments by leading forensic investigations, ensuring compliance, and resolving disputes. This position focuses on analyzing healthcare coding, billing, and payment integrity issues to identify fraud, waste, abuse, and operational inefficiencies. The ideal candidate brings a blend of healthcare expertise, investigative acumen, and regulatory knowledge. 

Job Duties:

Leads and manages forensic investigations related to healthcare billing, coding, and reimbursement practices Conducts detailed reviews of claims data, medical records, and billing documentation to assess compliance with federal and state regulations (e.g., CMS, HIPAA, False Claims Act) Develops and implements methodologies for identifying anomalies, trends, and potential fraud or abuse Collaborates with legal counsel, compliance officers, and external regulators during audits, litigation, or dispute resolution Prepares detailed reports, presentations, and expert opinions for internal stakeholders and external clients Supervises and mentors junior staff, ensuring high-quality deliverables and professional development Stays current on healthcare regulatory changes, payer policies, and industry trends Builds and maintains strong relationships with internal staff members and clients  Supports clients in developing corrective action plans and compliance programs to mitigate future risk Other duties as required

Supervisory Responsibilities:

Supervises the day-to-day workload on assigned engagements and reviews work product

Qualifications, Knowledge, Skills, and Abilities:

Education:

High School Diploma/GED AND seven (7) or more years of industry experience with healthcare revenue cycle, required; OR  Bachelor’s degree AND five (5) or more years of industry experience with healthcare revenue cycle, required

Experience:

Five (5) or more years of healthcare revenue cycle operations or regulatory compliance-based experience, required Three (3) or more years of experience with medical coding for large group practices and/or hospitals, required 

License(s)/Certification(s)/Affiliation(s):

Nationally recognized coding credential (e.g., CCS, CPC, RHIA, RHIT), required 

Software:

Proficiency in the use of Microsoft Office Suite, MS Project, Visio, and SharePoint, required Proficiency in the use of Epic, preferred

Other Knowledge, Skills & Abilities:

Executive presence, with the ability to act as primary contact on assigned engagements Excellent verbal and written communication skills, as well as presentation skills Strong analytical and advanced research skills related to industry trends, market competition and technology Solid organizational skills, especially the ability to meet project deadlines with a focus on details Ability to successfully multi-task while working independently or within a group environment Ability to work in a deadline-driven environment, and handle multiple projects simultaneously Able to interact effectively with people at all organizational levels of the Firm and with clients Ability to encourage a team environment on engagements, and contribute to the professional development of assigned team members Ad hoc travel may be required Additional certification applicable to this work such as Certified in Healthcare Compliance (CHC), Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), or similar Knowledge of applicable fraud statutes and regulations, and of federal guidelines on recoupments and other anti-FWA activity

 

Keywords: Healthcare Consulting, Healthcare Compliance, Revenue Cycle, Payment Integrity, Medical Coding, Medical Billing, Revenue Integrity, CCS, CPC, RHIA, RHIT, Audit, Risk Management

 

Individual salaries that are offered to a candidate are determined after consideration of numerous factors including but not limited to the candidate’s qualifications, experience, skills, and geography.

National Range: $95,000 - $160,000
Maryland Range: $95,000 - $160,000
NYC/Long Island/Westchester Range: $95,000 - $160,000