Senior Investigator – Hybrid/Remote Possible

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EmblemHealth
New York, NY, United States
68040 - 118800 USD / Year
  • Environmental
  • FlexTime
  • FullTime

Summary of Job Conduct complex, in-depth investigations of reported fraud involving the full range of healthcare products. Develop and maintain relationships with law enforcement (HHS-OIG, FBI, DOJ), regulatory agencies (DFS, MEDIC, OMIG, MFCU) and with industry peers. Provide guidance to the Fraud Investigators on SIU investigations and issues. Assist with anti-fraud training sessions and public speaking engagements.Responsibilities

  • Investigate complex cases of reported fraud involving the Company’s Medicaid healthcare product.

  • Develop leads from various sources to review for suspect activity.

  • Review claim files and develop action plans for the investigation.

  • Conduct highly comprehensive interviews/interrogations with providers.

  • Conduct medical records assessments, and CPT coding issues.

  • Provide guidance and mentor to the Fraud Investigators.

  • Answer and respond to SIU Fraud Hotline cases when assigned based on schedule.

  • Triage complaints that come to the SIU and follow through on resolution.

  • Participate in meetings with providers, attorneys, law enforcement on a case-by-case basis as needed.

  • Attend training, conferences, webinars to keep up to date on current trends and schemes of Fraud, Waste & Abuse.

  • May assist with fraud awareness training sessions and public speaking engagements.

  • Establish and maintain relationships with law enforcement (HHS-OIG, FBI), regulatory agencies (i.e DFS, MEDIC, OMIG, MFCU, NYS OAG), and with industry peers.

  • Refer cases to law enforcement or regulatory agencies as needed.

  • Periodically meet with representatives from law enforcement and regulatory agencies to keep updated on current trends.

  • Handle and respond to Requests for Information (RFI) from law enforcement and regulatory agencies.

  • Perform other duties as directed, assigned, or required.

Qualifications

  • Bachelor’s degree in criminal justice or related field.

  • AHFI and/or CFE certification (Preferred.

  • 4 – 6 years of relevant, professional work experience (Required)

  • Additional experience/specialized training may be considered in lieu of a bachelor’s degree (Required)

  • Professional investigation experience in economic or insurance related matters (Required)

  • Experience in insurance claims investigation or law enforcement (Preferred)

  • Strong knowledge of CPT and ICD9-CM coding, medical terminology, and treatment options (Required)

  • Proficiency in MS Office – Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc. (Required)

  • Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)

  • Attention to detail, critical thinking and problem-solving skills (Required)

  • Ability to monitor and review information from materials, events, or the environment, to detect or assess problems (Required)

Additional Information

  • Requisition ID: 1000002978
  • Hiring Range: $68,040-$118,800

Security DisclosureIf you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.Pay DisclosureAt EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual’s circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.EEOC StatementWe value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.Sponsorship StatementAt EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.

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