Job Description

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)

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