Fraud Investigator
1 month ago
Headquarters Office, 625 State Street, Schenectady, New York, United States of America Req #2125
Tuesday, August 13, 2024
Over 35 years strong and fueled by 1,700 smart, passionate employees across New York state and Vermont, MVP is full of opportunities to grow. We are a nationally recognized, award-winning leader for a reason. The beating heart of our company is a wide range of employees from a diverse set of backgrounds-tech people, numbers people, even people people-working together to make health insurance better. If you are ready to join a thriving, mission-driven company where you can create your own opportunities and make a positive difference-it's time to make a healthy career move to MVP
-This individual is responsible for investigating, reporting on and making recommendations on cases that have been identified as containing some element of fraudulent, wasteful and/or abusive activity.
-Ability to utilize various data management tools to help identify and/or research potential fraudulent, wasteful and abusive activity, including working knowledge of MS Office, Macess, Business Objects, Cognos, Facets, Care Radius, CMS websites, StarSentinel and iSight.
-Working knowledge of claim coding, such as CPT-4, HCPCS, ICD-9, and ICD-10 guidelines as they relate to claim data.
-Conduct on-site audits, including but not limited to audits of members' charts/records, members' accounts, and enrollment/eligibility.
-Organizes and conducts highly complex investigations, preparing informative written reports throughout the investigative process, in a timely and efficient manner, according to corporate and departmental SIU policies and procedures.
-Assists in investigations conducted by government agencies, including New York State Department of Insurance (Department of Financial Services), New York State Attorney General (Medicaid Fraud Unit), New York State Department of Health, US Attorney, Federal Bureau of Investigation, US Health and Human Services, CMS and other insurance company SIU staff.
-Submits reports of suspicious activity to federal and state agencies as required by statutory and regulatory requirements. Assists in creating provider education and corrective action plans. Provide information pertaining to investigations to the SIU Manager to be used as examples in annual SIU Fraud, Waste and Abuse corporate training. Testifies in criminal and civil legal proceedings as necessary.
-Stays current with Federal and State anti-fraud requirements, including HIPAA, CMS, Medicare, Medicaid and any corporate compliance initiatives or policies. May participate in meetings with providers, vendors, MVP employees and when appropriate, representatives from regulatory agencies.
-Develops and maintains a high degree of rapport and cooperation with federal, state and local law enforcement and regulatory agencies which can assist in investigative efforts. Keeps abreast of all current and upcoming legislation directives.
-Minimal travel may be required to obtain medical records pertaining to investigation and to conduct audits. Ability to maintain confidentiality and adhere to regulatory compliance issues as they exist and change from time to time; and Performs other related duties as assigned.
POSITION QUALIFICATIONS
Minimum Education:
AAS or BA/BS in Criminal Justice or related field required
Minimum Experience:
5 years insurance claims investigation or professional investigation experience with law enforcement agencies required.
Required Skills:
- Experience conducting FWA investigations required
- Superior judgement skills; excellent verbal and written communication skills
- Proactive and action-oriented
- A collaborative team player who works cross functionally with other teams to address issues
- Ability to work with all levels of management and employees; extremely detail-oriented with excellent organizational and analytical skills
- Experience working with law enforcement agencies, strong work ethic, unbiased approach to situations; perseverance in investigating, high-energy, data-driven, and focused with the ability to multi-task and operate in a fast-paced environment.
- Previous courtroom presentation experience preferred.
About MVP
MVP Health Care is a nationally recognized, not-for-profit health insurer caring for members in New York and Vermont. Committed to the complete well-being of our members and the communities we serve, MVP makes health insurance more convenient, more supportive, and more personal. We are powered by the ideas and energy of more than 1,700 diverse employees from all backgrounds, committed to having a positive impact on the health and wellness of everyone we serve.
At MVP, we are committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. Specific employment offers and associated compensation will be made individually based on several factors , including but not limited to geographic location ; relevant experience, education, and training; and the nature of and demand for the role.
In addition, we offer a comprehensive benefits package that includes:
- Considerable paid time away from work including PTO (Paid Time Off), s ick t ime, service t ime o ff, p aid h olidays, and f loating h olidays , allowing you to take time off when it suits you best.
- Competitive 401(k) employer matching and profit-sharing program to help you save for your retirement.
- Low premium health benefits including medical, dental, and vision coverage to support your well-being and that of your family.
- Life insurance and disability coverage to ensure financial security for you and your dependents.
- An array of optional benefit plans such as accident insurance and specified disease coverage to protect you from the unexpected.
- Full tuition reimbursement (up to the IRS limit) for approved courses and programs that support continuous learning.
- A best-in-class employee Well-Being program to support all dimensions of your health and wellness.
MVP Health Care is an Affirmative Action/ Equal Employment Opportunity (PDF). We recruit, employ, train, compensate, and promote without regard to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, disability, genetic information, veteran status, or any other basis, e.g., Pay Transparency (PDF), and the Know your Rights protected by applicable federal, state or local law. Any person with a disability needing special accommodations to the application process, please contact Human Resources at hr@mvphealthcare.com
Please apply and learn more - including how you may become a proud member of our team.
Other details
- Job Family Compliance
- Pay Type Salary
- Min Hiring Rate $70,925.00
- Max Hiring Rate $84,000.00
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