Fraud Examiner

Description and Requirements

The Fraud Examiner will be responsible for effectively providing support to both all SIU investigators by carrying out preliminary investigative tasks, conducting data analysis and supporting SIU responses to audits and external entities.

• Submit standard RFIs for routine reviews, inclusive of requests made to external business partners such as Medicare Broker Field Marketing Offices (FMO); and Ancillary Agencies for member involved and impacted allegations of Theft and or Assault.
• Perform routine and basic reviews such as the Medicare Rapid Disenrollment Reviews to identify failure(s) by all marketing personnel to perform required procedures and or documentation. This review will also identify potential fraudulent enrollments inclusive of an unreferred member complaint or allegation.
• Assist investigators with interviews,
• Assist with basic investigative actions such as member outreach, retrieval of internal records such as Claims, Sales Book of Business records, or review of recorded calls, and review of additional information utilized for determination for further investigative steps
• Assist with Marketing Incidents Committee Meetings by formatting all relevant documents for the meeting and compiling the finalized PDF version of the meeting packet; outreach to voting committee members and other relevant attendees to ensure attendance and required quantity (Quorum) of committee members' attendance meetings, assist with Marketing Incidents Committee Meeting by attending meetings and create meeting minutes, support HF SIU Internal and Marketing team by entering post Marketing Incidents Committee decisions and directives on the log; assist with tracking to ensure receipt of all relevant documentation of the completion of the committee's directives, and enter the receipt of the document(s) on the log.
• Assist SIU colleagues with general Internal and Marketing issues and problem solve
• Assist in Monitoring internal mailboxes for incoming investigative inquiries
• Additional duties as assigned, inclusive of minor administrative tasks in support of the department will be a requirement of this position

Minimum Qualifications:

• AA/AS degree from an accredited institution
• Intermediate Word and Outlook skills
• Intermediate/Advanced Excel skills including pivot tables and basic formulas
• Data analysis experience
• Prior experience in either personnel, state investigation/audit or other professional investigations
• Critical thinking, analytical skills, and teamwork experience
• Good oral and written communication skills including an ability to summarize data analysis and contribute to investigative reports=

Preferred Qualifications:

• Bachelor's Degree from an accredited institution
• Knowledge of Medicare and Medicaid and/or healthcare eligibility, compliance requirements, and or procedures
• Knowledgeable about applicable fraud statutes, regulations, CMS guidelines, Federal and State insurance reporting requirements.
• Professional conduct in dealing with persons internal and external to the organization
• Spanish or other language proficiency

Hiring Range:

• Greater New York City Area (NY, NJ, CT residents): $47,403 - $62,400
• All Other Locations (within approved locations): $41,101 - $60,320

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.