Fraud Investigator

Summary

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.The MJHS DifferenceAt MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high‑quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work‑life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve.Benefits include:Tuition Reimbursementfor all full and part‑time staffGenerous paid time off, including your birthday!Affordable and comprehensivemedical, dental and vision coverage for employee and family membersTwo retirement plans! 403(b) AND Employer Paid PensionFlexible spendingAnd MORE!MJHS companies are qualified employers under the Federal Government's Paid Student Loan Forgiveness Program (PSLF)Responsibilities:The SIU Fraud Investigator is responsible for identifying, investigating, and resolving allegations and indicators of fraud, waste, and abuse (FWA) involving providers, vendors, members, and other parties participating in Elderplan's product lines. Under the direction of the SIU Director and SIU Manager, this position conducts complex investigations in accordance with New York State Medicaid Managed Care requirements, Medicare regulations, contractual obligations, and Elderplan policies. The investigator analyzes claims, encounter, enrollment, medical record, and provider data; conducts interviews, field investigations, and on‑site audits, when necessary; prepares detailed investigative reports; and collaborates with compliance, legal, operational stakeholders, regulatory agencies, and law enforcement. The role supports Elderplan's Compliance Program and Fraud Prevention Program by mitigating financial losses, ensuring regulatory compliance, and promoting the integrity of the Medicare and Medicaid programs.Qualifications:An associate's or bachelor's degree in criminal justice or a related fieldA minimum of five years in the healthcare field working in fraud, waste, and abuse investigations and audits; orA minimum of five years of insurance claims investigation or law enforcement investigation experience; orA minimum of seven years of professional investigation experience involving economic or insurance related mattersCertified Professional Coder preferredCertified Coding Specialist preferredCertified Fraud Examiner preferredAbility to develop fraud investigationsAn intermediate or better level of proficiency in Microsoft Office. User knowledge of health care related computer systems/applications.Strong verbal and written communication, problem solving, organizational, and analytical skills requiredUnderstanding of Medicare Advantage, Part D laws and regulations preferred.Knowledge of HCPCS, ICD-10CM, and CPT required.Knowledge of reviewing medical records/documentation required#J-18808-Ljbffr

Job Description

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.The MJHS DifferenceAt MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high‑quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work‑life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve.Benefits include:Tuition Reimbursementfor all full and part‑time staffGenerous paid time off, including your birthday!Affordable and comprehensivemedical, dental and vision coverage for employee and family membersTwo retirement plans! 403(b) AND Employer Paid PensionFlexible spendingAnd MORE!MJHS companies are qualified employers under the Federal Government's Paid Student Loan Forgiveness Program (PSLF)Responsibilities:The SIU Fraud Investigator is responsible for identifying, investigating, and resolving allegations and indicators of fraud, waste, and abuse (FWA) involving providers, vendors, members, and other parties participating in Elderplan's product lines. Under the direction of the SIU Director and SIU Manager, this position conducts complex investigations in accordance with New York State Medicaid Managed Care requirements, Medicare regulations, contractual obligations, and Elderplan policies. The investigator analyzes claims, encounter, enrollment, medical record, and provider data; conducts interviews, field investigations, and on‑site audits, when necessary; prepares detailed investigative reports; and collaborates with compliance, legal, operational stakeholders, regulatory agencies, and law enforcement. The role supports Elderplan's Compliance Program and Fraud Prevention Program by mitigating financial losses, ensuring regulatory compliance, and promoting the integrity of the Medicare and Medicaid programs.Qualifications:An associate's or bachelor's degree in criminal justice or a related fieldA minimum of five years in the healthcare field working in fraud, waste, and abuse investigations and audits; orA minimum of five years of insurance claims investigation or law enforcement investigation experience; orA minimum of seven years of professional investigation experience involving economic or insurance related mattersCertified Professional Coder preferredCertified Coding Specialist preferredCertified Fraud Examiner preferredAbility to develop fraud investigationsAn intermediate or better level of proficiency in Microsoft Office. User knowledge of health care related computer systems/applications.Strong verbal and written communication, problem solving, organizational, and analytical skills requiredUnderstanding of Medicare Advantage, Part D laws and regulations preferred.Knowledge of HCPCS, ICD-10CM, and CPT required.Knowledge of reviewing medical records/documentation required#J-18808-Ljbffr