The Investigator within the Special Investigations Unit (SIU) will be responsible for effectively carrying out complex investigations of alleged misconduct and Fraud, Waste and Abuse by providers, representatives, employees, members, and others. This position is 100% remote. Scope of Responsibilities

• Conduct investigations of Providers, Representatives, Employees, Members, contracted groups and others
• Compile data into written reports: collect, utilize & interpret data obtained from a variety of reports and other sources, thereby identifying & documenting questionable patterns related to operation, and other practices which merit further investigation
• Investigations may be of a more complex nature i.e., multiple allegations; Medicaid and Medicare investigations or investigations involving extensive research, income verifications, and other criteria for eligibility
• Research investigations; prepare, review and edit investigation reports for submission to AVP, SIU and Marketing Incidents Committee
• Present relevant investigative findings: prepare and deliver presentation summaries to the Marketing Incidents Committee, and/or other groups as needed
• Log investigations, ensure accuracy, and completion of entries
• Inform the Special Investigations Unit leaders of potential or actual problem areas; identify & suggest corrective action or improvement
• Assist Special Investigations Unit leaders with Fraud, Waste and Abuse issues, and perform other duties as necessary or assigned
• Maintain assigned investigation files, document evidence, and prepare comprehensive investigation reports
• Establish good working relationships with Healthfirst employees & external contacts of the Special Investigations Unit Department, including Federal, State and Local law enforcement agencies

Minimum Qualifications

• Must have an Associate's degree from an accredited institution in criminal justice or related field, or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or seven years of professional investigative experience involving economic or insurance related matters
• Knowledgeable of applicable fraud statutes, CMS guidelines, federal and state requirements
• Must demonstrate a high degree of integrity & appropriate treatment of confidential information
• Must exhibit professional conduct in dealing with internal & external individuals and work with a level of sensitivity to target populations
• Ability to adhere to policies, rules and regulations
• Must have working knowledge of Microsoft Word, Excel, and Outlook

Preferred Qualifications

• Bachelor's degree from an accredited institution
• Strong critical thinking and analytical skills
• Knowledge of medical claims processing and investigations
• Knowledge of Medicare & Medicaid products

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070
• All Other Locations (within approved locations): $51,000 - $74,880

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

51000-74880