Senior Investigator - Hybrid/Remote Possible

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 records 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) Additional Information • Requisition ID 1000002978 • Hiring Range $68,040-$118,800 Apply To this Job