Join our Talent Network

Team Lead, Special Investigations Unit

Job Category: Compliance/Regulatory/Audit

Location: New York, NY, United States

Share: mail
Save Job Saved

Job Description

Description

The Team Lead (Supervisor), Special Investigations Unit (SIU) will be responsible for effectively leading a team of investigators in the day-to-day work of investigations providing support to both marketing and medical investigators by carrying out preliminary investigations and conducting data analysis of alleged Fraud, Waste and Abuse by providers, members, representatives and others.

  • Day-to-day coordination of internal investigations
  • Lead the Marketing Incidents Committee in effectively reporting and communicating trends, cases and committee directed follow-ups such as disciplinary actions
  • Assist Director, Special Investigations Unit in the triage and case management process of all caseloads from identification to closure so as to maximize due diligence, referrals and ROI while ensuring case documentation that enables high quality internal and external regulatory audit with strict adherence to regulatory and operational timelines
  • Work closely with Healthfirst business unit leadership and other key operational staff such as Sales Management and Training, Regulatory, Privacy and Human Resources to communicate potential fraud, waste and abuse
  • Confers with investigators to review evidence and determine further investigative steps
  • Conducts investigations into allegations of misconduct and fraud
  • Assists with reporting investigative findings
  • Participates in Fraud, Waste and Abuse detection and prevention
  • Ensures timely reporting of findings and trends
  • Identifies and suggests process improvements

NY State Requirements As Follows:

  • Bachelor’s degree in Criminal Justice or related field OR five years of insurance claims investigation experience and/or professional investigation experience with law enforcement agencies
  • Knowledgeable of applicable fraud statutes and regulations and CMS guidelines
  • Ability to work independently with excellent time management skills while still contributing to the needs of the Team
  • High degree of integrity as demonstrated by appropriate treatment of confidential information, adherence to policies, rules and regulations, professional conduct in dealing with persons internal and external to the organization, and sensitivity to target populations
  • Proficiency in MS Word, Excel, and Outlook
  • Strong critical thinking and analytical skills

Preferred Qualifications:  

  • Knowledge of medical claims processing and investigations
  • Knowledge of Medicare and Medicaid products
  • Intermediate MS Excel skills including pivot tables
  • Experience working in Special Investigations Unit

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

Share: mail

Similar Jobs

VP, Strategic Account Management

New York, NY, United States

VP Care Management LT

New York, NY, United States

UAS Registered Nurse

Field Office, NY, United States

Translator - Spanish

New York, NY, United States

Team Lead, Special Investigations Unit

New York, NY, United States

Summer Intern – IT Application Development

New York, NY, United States

Summer Intern – Enterprise Architecture

New York, NY, United States

Summer Intern - Marketing Personalization

New York, NY, United States

Summer Intern - Learning Delivery Team

New York, NY, United States

Summer Intern - Enterprise Analytics

New York, NY, United States

Summer Intern - Analytic Insights Team

New York, NY, United States

Strategic Account Management Associate

New York, NY, United States

Sr. Provider Advocate

New York, NY, United States

Sr. Java Engineer - Provider Portal

New York, NY, United States

Sr Java Developer

New York, NY, United States

Sr Enterprise Business Analyst

New York, NY, United States

Sr DevOps Engineer, Application Development

New York, NY, United States

Sr Data Scientist

New York, NY, United States

Sr Application Developer, ElasticSearch

New York, NY, United States

Sr Application Developer

New York, NY, United States

Interested in working for Healthfirst
Take the first step by joining our Talent Network today!

Join our Talent Network