Senior Investigator - Hybrid/Remote Possible
6 days ago
Hempstead
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 record 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)