Fraud Investigation Specialist

2 weeks ago


Schenectady, New York, United States MVP Health Care Full time
Position OverviewFraud Investigation Specialist

MVP Health Care is a leading not-for-profit health insurer dedicated to enhancing the well-being of our members and the communities we serve. We are seeking a skilled professional to join our team as a Fraud Investigation Specialist. This role is pivotal in safeguarding our organization against fraudulent activities and ensuring compliance with regulatory standards.

Key Responsibilities
  • Investigative Duties: Conduct thorough investigations into cases identified as potentially fraudulent, wasteful, or abusive. Prepare detailed reports and recommendations based on findings.
  • Data Analysis: Utilize various data management tools to identify and research suspicious activities. Proficiency in software such as MS Office and other analytical tools is essential.
  • Audit Execution: Perform on-site audits of member records, accounts, and eligibility to ensure compliance and accuracy.
  • Collaboration: Work closely with government agencies and law enforcement to assist in investigations and share findings as required.
  • Regulatory Compliance: Stay informed about federal and state anti-fraud regulations, ensuring adherence to HIPAA, CMS, and other compliance initiatives.
  • Training and Education: Contribute to the development of training materials and corrective action plans for providers based on investigative outcomes.
  • Confidentiality: Maintain strict confidentiality and uphold regulatory compliance throughout all investigative processes.

Qualifications
  • Education: An Associate's or Bachelor's degree in Criminal Justice or a related field is required.
  • Experience: A minimum of five years of experience in insurance claims investigation or professional investigation with law enforcement is necessary.
  • Skills: Strong judgment, excellent communication abilities, and a proactive approach are essential. Experience in conducting fraud investigations is required.
  • Team Collaboration: Ability to work effectively with various teams and levels of management, demonstrating attention to detail and strong organizational skills.

About MVP Health Care
MVP Health Care is committed to providing competitive compensation and comprehensive benefits to our employees. We value diversity and are dedicated to making a positive impact on the health and wellness of our members. Our benefits package includes generous paid time off, competitive retirement plans, and health coverage options to support the well-being of our employees and their families.

MVP Health Care is an Equal Employment Opportunity employer, promoting a diverse and inclusive workplace.
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