Fraud Examiner

The Fraud Examiner will be responsible for effectively providing support to both all SIU investigators by carrying out preliminary investigative tasks, conducting data analysis and supporting SIU responses to audits and external entities.

• Synthesize, analyze and process healthcare claims data and financial information in Excel, creation of tables/pivot tables for internal review and reporting
• Support HF SIU FWA team by maintaining an Agency Referral Log of all incoming agency requests for information (RFI)
• Obtain necessary information in response to RFIs to present to legal department for approval
• Monitor Restricted Recipient Program (RRP) by notifying appropriate departments of incoming informational packets
• Mailing of information regarding RRP to members
• Coordinate member and provider packets for members restricted by Member Review and Restriction Committee;
• Monitors internal mailboxes for incoming investigative inquiries
• Assist investigators with interviews, review of information and determination for further investigative steps; assist with Marketing Incidents Committee Meeting by attending meetings and managing notes and minutes, update Marketing Log with MIC decisions and directives
• Assist SIU colleagues with Fraud, Waste and Abuse issues and problem solve
• Additional duties as assigned, including but not limited to minor administrative tasks in support of the department will be a requirement of this position

Minimum Qualifications:

• AA/AS degree from an accredited institution
• Intermediate Word and Outlook skills
• Intermediate/Advanced Excel skills including pivot tables and basic formulas
• Data analysis experience
• Prior experience in either insurance claims investigation/audit or other professional investigations
• Critical thinking, analytical skills and teamwork experience
• Good oral and written communication skills including an ability to summarize data analysis and contribute to investigative reports

Preferred Qualifications:

• Bachelor’s Degree from an accredited institution
• Experience with Tableau and/or SAS
• Knowledge of Medicare and Medicaid and/or healthcare claims data
• Knowledge of medical claims processing and investigations and the ability to read medical records
• Knowledgeable about applicable fraud statutes, regulations, CMS guidelines, Federal and State insurance reporting requirements.
• Professional conduct in dealing with persons internal and external to the organization
• Spanish or other language proficiency

Compliance & Regulatory Responsibilities: N/A

License/Certification: N/A

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

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $48,600 - $65,960

• All Other Locations (within approved locations): $42,200 - $62,400

As 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.

About Us

Healthfirst is New York’s largest not-for-profit health insurer offering it’s nearly 1.7 million members access to high-quality, affordable healthcare. As part of the community for nearly 30 years, Healthfirst’s unique advantage is rooted in its belief that good health doesn’t start in a doctor’s office. The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well-being. This value-based care model is the foundation of the company’s sustained growth in one of the most dynamic markets in the country. So, if you are passionate about what you do and want to work for a company that is focused on the future and dedicated to making a difference in people’s lives, then Healthfirst is for you.

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