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Senior Investigator Jobs

Company

EmblemHealth
Address , New York, Ny
Employment type
Salary $75,000 - $95,000 a year
Expires 2023-06-13
Posted at 1 year ago
Job Description
Summary of Position
  • Review medical records with clinical interpretation for investigative review.
  • Conduct complex, in-depth investigations of reported fraud involving the full range of healthcare products.
  • Review claims data and medical documentation to ensure proper coding of claims.
  • Provide guidance to the Fraud Investigators conducting anti-fraud training sessions and public speaking engagements.


Principal Accountabilities
  • Develop leads from various sources to review for suspect activity.
  • Perform various related duties as assigned: conduct medical records assessments, CPT coding issues, etc.
  • Review claim files and develop action plans for the investigation.
  • Investigate complex cases of reported fraud involving the Company’s full range of healthcare products.
  • Provide in depth review of medical records as it relates to investigations of fraud waste and abuse for leadership and
  • Conduct highly comprehensive interviews/interrogations with providers.
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.
  • 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
  • Establish and maintain liaisons with law enforcement, regulatory agencies, and with industry peers.
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
  • Working knowledge of applicable laws/regulations. (R)
  • 3+ years of professional investigation experience with a law enforcement agency. (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
  • 4 – 6+ years of relevant, professional work experience. (R)
  • Proficiency with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.). (R)
  • Strong knowledge of CPT and ICD9-CM coding, medical terminology, and treatment options. (R)
  • Strong communication skills (verbal, written, interpersonal) with all types/levels of audience. (R)

Additional Information

  • Requisition ID: 1000000461
  • Hiring Range: $75,000-$95,000