This position is 100% remote.
Scope of Responsibilities
Conduct investigations of Providers, Representatives, Employees, Members, contracted groups and others
Compile data into written reports: collect, utilize & interpret data obtained from a variety of reports and other sources, thereby identifying & documenting questionable patterns related to operation, and other practices which merit further investigation
Investigations may be of a more complex nature i.e., multiple allegations; Medicaid and Medicare investigations or investigations involving extensive research, income verifications, and other criteria for eligibility
Research investigations; prepare, review and edit investigation reports for submission to AVP, SIU and Marketing Incidents Committee
Present relevant investigative findings: prepare and deliver presentation summaries to the Marketing Incidents Committee, and/or other groups as needed
Log investigations, ensure accuracy, and completion of entries
Inform the Special Investigations Unit leaders of potential or actual problem areas; identify & suggest corrective action or improvement
Assist Special Investigations Unit leaders with Fraud, Waste and Abuse issues, and perform other duties as necessary or assigned
Maintain assigned investigation files, document evidence, and prepare comprehensive investigation reports
Establish good working relationships with Healthfirst employees & external contacts of the Special Investigations Unit Department, including Federal, State and Local law enforcement agencies
Minimum Qualifications
Must have an Associate's degree from an accredited institution in criminal justice or related field, or five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, or seven years of professional investigative experience involving economic or insurance related matters
Knowledgeable of applicable fraud statutes, CMS guidelines, federal and state requirements
Must demonstrate a high degree of integrity & appropriate treatment of confidential information
Must exhibit professional conduct in dealing with internal & external individuals and work with a level of sensitivity to target populations
Ability to adhere to policies, rules and regulations
Must have working knowledge of Microsoft Word, Excel, and Outlook
Preferred Qualifications
Bachelor's degree from an accredited institution
Strong critical thinking and analytical skills
Knowledge of medical claims processing and investigations
Knowledge of Medicare & Medicaid products
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLCshallnotdiscriminateagainstanydisabledemployeeorapplicantinregard to any position for which the employee or applicant is otherwise qualified.
If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.
All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.
Hiring Range*:
Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070
All Other Locations (within approved locations): $51,000 - $74,880
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.