Fraud Investigator

MJHS; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

Elderplan is seeking a SIU Fraud Investigator in New York, NY to identify, investigate, and resolve fraud, waste, and abuse involving providers, vendors, and members. Under the direction of the SIU Director and Manager, you will analyze claims, enrollment, medical records, and provider data, and conduct interviews and on-site audits when needed.

You will prepare investigative reports, collaborate with compliance, legal, and regulators, support the Compliance Program and Fraud Prevention Program,

Qualifications

• Associate's or bachelor's degree in criminal justice or a related field.
• Experience in healthcare fraud, waste and abuse investigations or audits preferred.
• Experience in insurance claims or law enforcement investigations preferred.

Responsibilities

• Identify, investigate, and resolve allegations of fraud, waste, and abuse.
• Analyze claims, enrollment, medical records, and provider data.
• Conduct interviews, field investigations, and on-site audits when necessary.
• Prepare detailed investigative reports and collaborate with compliance, legal, and regulators.
• Support Elderplan's Compliance Program and Fraud Prevention Program.

Skills

Fraud investigations

Interviews

Data analysis

Report writing

Communication

Problem solving

Regulatory knowledge

Attention to detail

Analytical skills

On-site audits

Education

Associate's or Bachelor's degree in criminal justice or a related field

Tools

Microsoft Office

Healthcare IT systems

Job description

Come lead with us at New York, NY
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 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.

• 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
• Certified Professional Coder preferred
• Certified Coding Specialist preferred
• Certified Fraud Examiner preferred
• Ability to develop fraud investigations
• An intermediate or better level of proficiency in Microsoft Office. User knowledge of health care related computer systems/applications.
• Strong verbal and written communication, problem solving, organizational, and analytical skills required
• Understanding of Medicare Advantage, Part D laws and regulations preferred.
• Knowledge of HCPCS, ICD-10CM, and CPT required.
• Knowledge of reviewing medical records/documentation required