Senior Fraud Investigator

Job Type

Full Time




330 West 42nd Street
New York
New York
United States


The 1199SEIU Benefit & Pension Funds provide comprehensive health, pension, and quality of life benefits to unionized workers represented by 1199SEIU United Healthcare Workers East. We are among the largest labor-management funds in the nation, covering 400,000 members and their families.


If you’re ready for the brightest career future, join us in this excellent opportunity to showcase your talents. We are currently seeking an experienced Senior Fraud Investigator for our Fraud & Abuse department. 


  • Perform accurate and reliable medical record review audits and investigations to verify if services are supported by clinically appropriate documentation; determine if services were appropriately administered; and/or validate coding and billing accuracy
  • Utilize extensive knowledge of medical terminology, ICD-9-CM, HCPC Level ll and CPT coding along with analysis
  • Recognize and adhere to national and local coding and billing guidelines in order to maintain coding accuracy and excellence
  • Produce reliable, accurate and timely written reports for internal and/external review detailing audit findings, based on industry standard(s) and/or internal policy and procedure
  • Recommend possible interventions for loss control and risk avoidance based on the outcome of the investigation
  • Coordinate with various internal customers to gather documentation pertinent to investigations
  • Incorporate communication skills to work with physicians, other health professionals, attorneys as well as external regulatory agencies and law enforcement personal
  • Communicate effectively and collaboratively with internal staff, leadership and external customers in a professional manner
  • Conduct settlement negotiations with providers and/or attorneys
  • Maintain the confidentiality required of the organization and the department
  • Follow all Health Insurance Portability and Accountability Act (HIPAA) and Personal Health Information (PHI) requirements and regulations
  • Perform additional duties and projects as assigned by management
  • Must meet performance standards including attendance and punctuality



  • Bachelor’s Degree in Business, Criminal Justice or related field or equivalent training and experience required
  • Minimum three (3) years experience with medical coding and medical record review audits required
  • Minimum three (3) years experience in healthcare fraud, insurance fraud or other related fraud investigations required
  • Intermediate skill level in Microsoft Word and Microsoft  Excel required
  • Certified Professional Coder (CPC) or other recognized coding certification and/or Accredited Healthcare Fraud Investigator (AFHI) preferred
  • Knowledge of medical coding and medical terminology
  • Excellent report writing skills
  • Knowledge of claims business operations including claims processing, and reimbursement procedures, solid understanding of fraud detection and prevention practices
  • Knowledge of data analysis of claims and documenting findings on spreadsheets
  • Excellent interpersonal and communication skills – oral, written and listening


medical, dental, no copay, prescription, vision, tuition reimbursement, child care

Professional Level

Entry level

Minimum Education Required

4-year degree

How To Apply

We offer a competitive salary, an excellent fully employer-paid comprehensive benefits package and talented professional colleagues. For consideration and to apply, please visit us at Please mention you saw this ad in Idealist. We are an Equal Opportunity Employer.