Fraud Investigator

Fraud Investigator

Headquarters Office, 625 State Street, Schenectady, New York, United States of America Req #2125

Tuesday, August 27, 2024

At MVP Health Care, we're on a mission to create a healthier future for everyone - which requires innovative thinking and continuous improvement. To achieve this, we're looking for a Fraud Investigator to join #TeamMVP. This is the opportunity for you if you have a passion for investigating and making recommendations as well as a love for your community.

What's in it for you:

• Growth opportunities to uplevel your career
• A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team
• Competitive compensation and comprehensive benefits focused on well-being
• An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work for and one of the Best Companies to Work For in New York

Qualifications you'll bring:

• An Associates or Bachelors degree or equivalent combination of education and related experience i n Criminal Justice or related field required
• The availability to work full-time, hybrid (two days a week in office) to Schenectady, NY
• 5 years insurance claims investigation or professional investigation experience with law enforcement agencies 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
• Curiosity to foster innovation and pave the way for growth
• Humility to play as a team
• Commitment to being the difference for our customers in every interaction

Your key responsibilities:

• 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.
• Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

Where you'll be:

Schenectady, NY, hybrid in office two days a week

Pay Transparency
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.

Affirmative Action
MVP 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 .