Fraud Investigator

1199SEIU Benefit and Pension Funds; New York (NY); On-site; USD 70,000 - 95,000; Full time

Job summary

1199SEIU Benefit and Pension Funds seeks a dedicated investigator to manage the Fraud & Abuse hotline, conduct confidential investigations, and coordinate evidence-based reporting. The role involves analyzing medical records for billing appropriateness, maintaining case files, and liaising with providers and vendors.

The candidate will prepare reports, support strategic case development, and ensure compliance with civil evidence rules while upholding confidentiality and professional standards.

Qualifications

• Bachelor’s Degree in Criminal Justice or related field required.
• Minimum 2 years in fraud investigations or equivalent training.
• Knowledge of ERISA/Taft-Hartley Plan operations preferred.
• Proven track record in investigative file preparation and evidence indexing.
• Excellent investigative, analytical, and project management skills.
• Ability to maintain confidentiality.
• Proficiency in Microsoft Office and case-tracking software.
• Data analysis experience and documenting findings in a spreadsheet.
• Strategic, analytical, problem-solving, organizational, time management, and communication skills.
• Travel availability.

Responsibilities

• Operate the Fraud & Abuse hotline intake and enter cases into tracking database.
• Conduct confidential investigations; collect evidence and communicate findings to supervisor.
• Analyze patient medical records to assess billing and reimbursement appropriateness.
• Prepare and maintain investigative case files and evidence indexes.
• Participate in committees and meetings on case strategies and provider negotiations.
• Manage recovery of overpayments, issue refund letters, settlement agreements, and repayment plans.
• Prepare Monthly Management, Case Tracking, and Recovery/Collections reports.
• Conduct research to develop supporting evidence.
• Interview providers, members, and witnesses to gather information per civil rules of evidence.
• Coordinate outsourced anti-fraud services with external vendors.
• Develop communications for providers and vendors.
• Attend training and seminars to stay updated on industry standards and trends.
• Perform special projects as directed by management.

Skills

Investigations

Data analysis

Communication

Interviews

Confidentiality

Report writing

Education

Bachelor’s Degree in Criminal Justice or related field

Tools

Microsoft Office

Case management software

Job description

Responsibilities

• Responsible for operating the Fraud & Abuse hotline involving the intake of all complaints and entry into the Department’s case tracking database.
• Conduct confidential investigations of all assigned cases: collect support evidence, data analysis, identify overpayments, apply industry guidelines, and communicate findings to Assistant Director
• Analyze and interpret patient medical records pertaining to fraud and abuse investigations and determines appropriateness of billing and reimbursement
• Prepare and maintain investigative case files including the preparation of reports and indexing of all evidence.
• Participate in various meetings (e.g., committees and attorneys) involving case strategies development, provider negotiations, information sharing, etc.
• Manage the recovery of overpayments, issue refund demand letters, settlement agreements, administrative action letters, repayment plans; track suspensions and withholding activities
• Prepare Monthly Management, Case Tracking, and Recovery/Collections reports.
• Conduct research to develop supporting evidence
• Conduct comprehensive interviews with providers, members, and witnesses to obtain information that is generally acceptable under the civil rules of evidence.
• Utilize expertise of outside vendors to coordinate outsourced anti-fraud services (e.g., maintenance of the fraud detection software/database, expert opinions, medical review, onsite facility audit, fraud detection data analysis etc.)
• Develop communications to effectively communicate with providers, vendors etc.
• Attend internal and external training seminars to maintain a high level of professional excellence, and knowledge of industry standards and trends through training
• Perform special projects and assignments as directed by management

Qualifications

• Bachelor’s Degree in Criminal Justice or related field required
• Minimum of two (2) years experience conducting or assisting in fraud investigations or the equivalent combination of education, experience, and training that provides the required knowledge, skills, and abilities for the position.
• Knowledge of the business operations of an ERISA/Taft-Hartley Plan (preferred, but not required);
• Proven track record in the preparation and maintaining of investigative case files to include the preparation of reports and indexing of all evidence.
• Excellent investigative, technical, analytical, and/or project management skills.
• Ability to maintain the highest level of confidentiality.
• Proficiency in Microsoft Office applications (i.e., Word, Excel, PowerPoint and Outlook) and internal or vendor provided case tracking software.
• Knowledge of performing data analysis and documenting findings in a spreadsheet.
• Strategic planning, analytical and problem-solving skills; excellent organizational, record keeping, operations management and time management skills; excellent interpersonal and communications skills – oral, written, and listening
• Excellent report writing skills
• Must be able to travel