Investigator

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

MetroPlusHealth is seeking a highly qualified candidate for an Investigator role within our Special Investigations Unit. The Investigator will support the Plan in the detection, prevention and investigation of suspected fraud, waste, and abuse. The position reports to the Director of Special Investigations Unit.

• Investigates allegations of fraud, waste, and abuse from internal and external sources at multiple levels of complexity
• Assists in conducting claims investigations and audits to identify potential Fraud, Waste and Abuse
• Maintains thorough documentation of cases and refers issues to the appropriate parties
• Develops reports and other monitoring parameters, utilizing multiple internal/external resources to identify outliers and areas of risk
• Provides case updates and coordinates with the SIU team and other MetroPlusHealth stakeholders to ensure case progression and resolution
• Prepare detailed and summary reports to internal and external parties including Federal and State agencies
• Completes special projects and audits as required

• An Associate's Degree or Bachelor's Degree in criminal justice or a related field; and
• Relevant work experience meeting one of the following criteria:
• 5 years in the healthcare field working in fraud, waste and abuse investigations and audits; (or)
• 5 years of insurance claims investigation experience or professional investigation experience with law enforcement agencies; (or)
• 7 years of professional investigation experience involving economic or insurance related matters
• Medical Coding Experience - Preferred
• Preferred candidate will have experience in Medicaid, Medicare, and Marketplace/Exchange

Licensure and/or Certification Required:

• Certified Fraud Examiner designation and /or Accredited Healthcare Fraud Investigator - Preferred

Professional Competencies:

• Integrity and Trust
• Customer Focus
• Excellent Microsoft Office Suite skills
• Written/Oral Communication