Senior Investigator, Compliance, Health Insurance - Remote
Location: New York, New York
Type: Full Time
Salary: Hiring Range $75,000 - $95,000
4 Year Degree
Telecommuting is allowed.
Internal Number: 1000000461
Summary of Position
- Conduct complex, in-depth investigations of reported fraud involving the full range of healthcare products. - Provide guidance to the Fraud Investigators conducting anti-fraud training sessions and public speaking engagements. - Review medical records with clinical interpretation for investigative review. - Review claims data and medical documentation to ensure proper coding of claims.
- Investigate complex cases of reported fraud involving the Company’s full range of healthcare products. - 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. - Perform various related duties as assigned: conduct medical records assessments, CPT coding issues, etc. - Provide in depth review of medical records as it relates to investigations of fraud waste and abuse for leadership and peer case review. - Provide review and assessment of coding on claims data and medical documentation to ensure it is accurate per diagnosis or conditions outlined in medical files. - Establish and maintain liaisons with law enforcement, regulatory agencies, and with industry peers. - Refer cases to law enforcement agencies/escalate to appropriate internal channels as needed. - Conduct fraud awareness training sessions and public speaking engagements. Provides guidance to the Fraud Investigators.
Education, Training, Licenses, Certifications
- Bachelor’s degree in Criminal Justice or related field - Certified Coder - Nursing License (LPN; RN preferred)
Relevant Work Experience, Knowledge, Skills, and Abilities
- 4 – 6+ years of relevant, professional work experience. (R) - 3+ years of professional investigation experience with a law enforcement agency. (R) - Strong knowledge of CPT and ICD9-CM coding, medical terminology, and treatment options. (R) - Working knowledge of applicable laws/regulations. (R) - Strong communication skills (verbal, written, interpersonal) with all types/levels of audience. (R) - Proficiency with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.). (R) - Detail oriented; highly organized; ability to maintain discretion at all times. (R) - Ability to successfully manage multiple tasks simultaneously with competing priority levels and deadlines. (R)
For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable, because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.
To protect the health and safety of our workforce, members, patients, and the communities we serve, the EmblemHealth family of companies require all new employees to be fully vaccinate...d for COVID-19. Exemption/reasonable accommodations may be granted because of 1) a qualifying medical condition or disability that makes getting the vaccine unsafe for the individual, or 2) objection on the basis of sincerely held religious beliefs and/or practices.
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth