Senior Investigator

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