Investigator I, II

Description SHIFT: Day JobSCHEDULE: Full-timeInvestigator I, IIThis position is a remote role that must be located within 1.5 hours of New York City with the ability to travel up to 10% to NYC (once offices are back open). Responsible for the identification, investigation and development of cases against perpetrators of healthcare fraud in order to recover corporate and client funds paid on fraudulent claims. Primary duties may include, but are not limited to: Claim reviews for appropriate coding, data mining, entity review, law enforcement referral, and use of proprietary data and claim systems for review of facility, professional and pharmacy claims.

Responsible for identifying and developing enterprise-wide specific healthcare investigations that may impact more than one company health plan, line of business and/or state.

Must be able to effectively establish rapport and on-going working relationship with law enforcement.

May interface internally with Senior level management and legal department throughout investigative process.

May assist in training of internal and external entities.

Assists in the development of policy and/or procedures to prevent loss of company assets.

Health insurance, law enforcement experience preferred.

Qualifications Investigator I Requires BA/BS, 2+ years related experience preferably in healthcare insurance departments such as Grievance and Appeals, Contracting or Claim Operations, law enforcement; or any combination of education and experience, which would provide an equivalent background.

Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.

Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

Healthcare medical coding experience strongly preferred

Microsoft Excel

Must be able to sit live within 1.5 hours of New York City. Ability to travel up to 10% for state meetings (post COVID).

Investigator IIRequires BA/BS degree, 3+ years of healthcare fraud investigations experience; or any combination of education and experience, which would provide an equivalent background.

Fraud certification from CFE, AHFI, AAPC or coding certificates preferred.

Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred.

Healthcare medical coding experience strongly preferred

Microsoft Excel

Must be able to sit live within 1.5 hours of New York City. Ability to travel up to 10% for state meetings (post COVID).

An Equal Opportunity/Employer/Disability/Veteran.REQNUMBER: PS40467-New%20York