Description and RequirementsThe Investigator within the Special Investigations Unit (SIU) will be responsible for effectively carrying out complex investigations of alleged misconduct and Fraud, Waste and Abuse by providers, representatives, employees, members, and others.This position is 100% remote.Scope of ResponsibilitiesConduct investigations of Providers, Representatives, Employees, Members, contracted groups and othersCompile 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 investigationInvestigations 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 eligibilityResearch investigations; prepare, review and edit investigation reports for submission to AVP, SIU and Marketing Incidents CommitteePresent relevant investigative findings: prepare and deliver presentation summaries to the Marketing Incidents Committee, and/or other groups as neededLog investigations, ensure accuracy, and completion of entriesInform the Special Investigations Unit leaders of potential or actual problem areas; identify & suggest corrective action or improvementAssist Special Investigations Unit leaders with Fraud, Waste and Abuse issues, and perform other duties as necessary or assignedMaintain assigned investigation files, document evidence, and prepare comprehensive investigation reportsEstablish good working relationships with Healthfirst employees & external contacts of the Special Investigations Unit Department, including Federal, State and Local law enforcement agenciesMinimum QualificationsMust 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 mattersKnowledgeable of applicable fraud statutes, CMS guidelines, federal and state requirementsMust demonstrate a high degree of integrity & appropriate treatment of confidential informationMust exhibit professional conduct in dealing with internal & external individuals and work with a level of sensitivity to target populationsAbility to adhere to policies, rules and regulationsMust have working knowledge of Microsoft Word, Excel, and OutlookPreferred QualificationsBachelor's degree from an accredited institutionStrong critical thinking and analytical skillsKnowledge of medical claims processing and investigationsKnowledge of Medicare & Medicaid productsHiring Range:Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070All Other Locations (within approved locations): $51,000 - $74,880As 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. 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, LLC shall not discriminate against any disabled employee or applicant in regard 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.Know Your Rights