Senior Fraud Investigator-NYC (Hybrid)

Responsibilities

• Conducts investigations into allegations of fraud, waste, or abuse, including preliminary assessments and full end-to-end case work.

• Reviews and analyzes medical records, claims data, enrollment data, and other documentation to evaluate potential FWA.

• Performs coding, billing, reimbursement, and medical necessity assessments based on CPT, HCPCS, ICD-9/10, DRG, and related coding guidelines.

• Uses advanced data mining techniques to identify aberrant billing patterns, outliers, and other indicators of fraudulent activity.

• Produces reliable, accurate and timely written investigative reports for internal and/external review detailing investigation findings, based on industry standard(s) and/or internal policy and procedure.

• Recommends possible interventions for loss control and risk avoidance based on the outcome of the investigation.

• Coordinates with various internal customers to gather documentation pertinent to investigations.

• Incorporates communication skills to work with physicians, other health professionals, attorneys as well as external regulatory agencies and law enforcement personnel.

• Communicate effectively and collaboratively with internal staff, leadership and external customers in a professional manner.

• Conducts 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

Qualifications

• Bachelor’s degree in business, criminal justice or related field.

• Certified Professional Coder (CPC), Accredited Healthcare Fraud Investigator (AFHI), Certified Insurance Fraud Investigator (CIFI), and/or Certified Economic Crime Forensic Examiner (CECFE) preferred (but not required).

• Minimum three (3) years’ experience with medical coding and medical record review performed required.

• Minimum three (3) years’ experience in healthcare industry within a Special Investigation Unit (SIU) or equivalent governmental agency responsible for investigating healthcare fraud required.

• Knowledge of medical coding and medical terminology.

• Experience using STARSSolutions or other healthcare FWA case management and detection software preferred (but not required).

• Proven track record in conducting investigations and/or the identification and pursuit of the recovery of overpayments.

• Excellent report writing skills.

• Knowledge of claims processing, reimbursement procedures, and a solid understanding of fraud detection and prevention practices.

• Knowledge of data analysis of claims and documenting findings on spreadsheets.

• Proficiency in Microsoft Office/Suite applications (Excel, Word, PowerPoint, Outlook, etc.).

• Excellent interpersonal and communication skills – oral, written and listening.

This is a hybrid posiiton that will require you to report to our offices in Midtown Manhattan.