Fraud Investigator

1199SEIU Benefit and Pension Funds; New York (NY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

1199SEIU Benefit and Pension Funds seeks a dedicated investigator to manage the Fraud & Abuse hotline, conduct confidential investigations, and analyze medical records for fraud and overpayments. The role involves preparing thorough case files, coordinating with attorneys and vendors, and communicating findings to leadership.

Applicants should have a Bachelor’s degree in criminal justice or related field, at least two years in fraud investigations, and strong MS Office skills.

Qualifications

• Must have strong investigative, analytical, and reporting abilities.
• Experience handling fraud investigations and maintaining case files.
• Proficiency with MS Office and case-tracking systems; ability to handle sensitive information.

Responsibilities

• Operate Fraud & Abuse hotline and enter complaints into the case-tracking database.
• Conduct confidential investigations and collect evidence for case files.
• Analyze medical records to assess billing and reimbursement appropriateness.
• Prepare investigative reports and index all evidence.
• Coordinate with internal teams and external vendors on anti-fraud services.
• Develop communications with providers and maintain professional standards.

Skills

Analytical skills

Investigation skills

Communication skills

Project management

Education

Bachelor’s Degree in Criminal Justice

Tools

Microsoft Office

Case tracking 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

Requisition #: 7528

# of openings: 1

Employment Type: Full time

Position Status: Permanent

Category: Non-Bargaining

Workplace Arrangement: Hybrid

Fund: 1199SEIU National Benefit Fund

Job Classification: Exempt

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