Fraud Investigator

Metropolitan Jewish Health System; New York (NY); On-site; USD 77,000 - 93,000; Full time

Benefits offered by this job

Tuition Reimbursement

Paid time off (birthday included)

Medical, dental and vision coverage

403(b) and employer paid pension

Flexible spending

And MORE!

Job summary

Metropolitan Jewish Health System is seeking a SIU Fraud Investigator to identify, investigate, and resolve fraud, waste and abuse across Elderplan’s product lines.

Under the direction of the SIU Director, you will analyze claims and provider data, conduct interviews and audits, and prepare detailed reports for compliance, legal and regulatory partners.

Joining MJHS offers comprehensive benefits, development opportunities, and a commitment to integrity and patient care.

Qualifications

• Minimum five years in healthcare fraud, waste and abuse investigations and audits, or
• Minimum five years of insurance claims investigation or law enforcement investigation experience, or
• Minimum seven years of professional investigation experience involving economic or insurance related matters

Responsibilities

• Identify, investigate, and resolve allegations and indicators of fraud, waste and abuse (FWA) involving providers, vendors, members and other parties participating in Elderplan’s product lines.
• Analyze claims, encounter, enrollment, medical record and provider data; conduct interviews, field investigations and on-site audits when necessary; prepare detailed investigative reports.
• Collaborate with compliance, legal, operational stakeholders, regulatory agencies and law enforcement to support Elderplan's compliance and fraud prevention programs.

Education

Associate or Bachelor degree in criminal justice

Job description

Overview

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

The MJHS Difference

At MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve.

Benefits include:

• Tuition Reimbursementfor all full and part-time staff
• Generous paid time off, including your birthday!
• Affordable and comprehensive medical, dental and vision coverage for employee and family members
• Two retirement plans! 403(b) AND Employer Paid Pension
• Flexible spending
• And MORE!

MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)

Responsibilities

The SIU Fraud Investigator is responsible for identifying, investigating, and resolving allegations and indicators of fraud, waste, and abuse (FWA) involving providers, vendors, members, and other parties participating in Elderplan’s product lines. Under the direction of the SIU Director and SIU Manager, this position conducts complex investigations in accordance with New York State Medicaid Managed Care requirements, Medicare regulations, contractual obligations, and Elderplan policies. The investigator analyzes claims, encounter, enrollment, medical record, and provider data; conducts interviews, field investigations, and on-site audits, when necessary; prepares detailed investigative reports; and collaborates with compliance, legal, operational stakeholders, regulatory agencies, and law enforcement. The role supports Elderplan's Compliance Program and Fraud Prevention Program by mitigating financial losses, ensuring regulatory compliance, and promoting the integrity of the Medicare and Medicaid programs.

Qualifications

• An associate’s or bachelor’s degree in criminal justice or a related field
• A minimum of five years in the healthcare field working in fraud, waste, and abuse investigations and audits; or
• A minimum of five years of insurance claims investigation or law enforcement investigation experience; or
• A minimum of seven years of professional investigation experience involving economic or insurance related matters

Min

USD $77,099.34/Yr.

Max

USD $92,519.21/Yr.