Fraud Investigator

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 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.

• An associate’s or bachelor’s degree in criminal justice or a related field
• A minimum of five years in the healthcare field working in fraud, waste, and abuse investigations and audits; or
• A minimum of five years of insurance claims investigation or law enforcement investigation experience; or
• A minimum of seven years of professional investigation experience involving economic or insurance related matters
• Certified Professional Coder preferred
• Certified Coding Specialist preferred
• Certified Fraud Examiner preferred
• Ability to develop fraud investigations
• An 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 required
• Understanding of Medicare Advantage, Part D laws and regulations preferred.
• Knowledge of HCPCS, ICD-10CM, and CPT required.
• Knowledge of reviewing medical records/documentation required