Summary of Job Conduct complex, in-depth investigations of reported fraud involving the full range of healthcare products. Develop and maintain relationships with law enforcement (HHS-OIG, FBI, DOJ), regulatory agencies (DFS, MEDIC, OMIG, MFCU) and with industry peers. Provide guidance to the Fraud Investigators on SIU investigations and issues. Assist with anti-fraud training sessions and public speaking engagements. Responsibilities
- Investigate complex cases of reported fraud involving the Company's Medicaid healthcare product.
- Develop leads from various sources to review for suspect activity.
- Review claim files and develop action plans for the investigation.
- Conduct highly comprehensive interviews/interrogations with providers.
- Conduct medical records assessments, and CPT coding issues.
- Provide guidance and mentor to the Fraud Investigators.
- Answer and respond to SIU Fraud Hotline cases when assigned based on schedule.
- Triage complaints that come to the SIU and follow through on resolution.
- Participate in meetings with providers, attorneys, law enforcement on a case-by-case basis as needed.
- Attend training, conferences, webinars to keep up to date on current trends and schemes of Fraud, Waste & Abuse.
- May assist with fraud awareness training sessions and public speaking engagements.
- Establish and maintain relationships with law enforcement (HHS-OIG, FBI), regulatory agencies (i.e DFS, MEDIC, OMIG, MFCU, NYS OAG), and with industry peers.
- Refer cases to law enforcement or regulatory agencies as needed.
- Periodically meet with representatives from law enforcement and regulatory agencies to keep updated on current trends.
- Handle and respond to Requests for Information (RFI) from law enforcement and regulatory agencies.
- Perform other duties as directed, assigned, or required.
Qualifications
- Bachelor's degree in criminal justice or related field.
- AHFI and/or CFE certification (Preferred.
- 4 - 6+ years of relevant, professional work experience (Required)
- Additional experience/specialized training may be considered in lieu of a bachelor's degree (Required)
- Professional investigation experience in economic or insurance related matters (Required)
- Experience in insurance claims investigation or law enforcement (Preferred)
- Strong knowledge of CPT and ICD9-CM coding, medical terminology, and treatment options (Required)
- Proficiency in MS Office - Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc. (Required)
- Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences (Required)
- Attention to detail, critical thinking and problem-solving skills (Required)
- Ability to monitor and review information from materials, events, or the environment, to detect or assess problems (Required)
Additional Information
- Requisition ID: 1000002978
- Hiring Range: $68,040-$118,800
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EmblemHealth
Feb 27, 2026