- Degree in Criminal Justice or related field preferred.
- Bachelor's degree or four (4) years of equivalent experience required.
- Designation as an Accredited Health Care Fraud Investigator preferred.
- Incumbent must meet one of the minimum qualifications outlined below, in line with New York State requirements:
- Associate's or Bachelor's degree in criminal justice or related field, or
- Minimum five (5) years of insurance claims investigation experience or professional investigation experience with law enforcement agencies or
- Minimum seven (7) years of professional investigation experience involving economic or insurance related matters.
- Experience with CPT and ICD-9 coding used in health care benefits and claims processing required.
- Experience working with complex contracts with healthcare systems, large medical groups, hospitals, ancillary providers, individual practitioners, and members for Commercial, Medicare, and Medicaid lines of business required.
- Experience with payment methodologies required.
- Experience working with law enforcement, responding to subpoenas and/or testifying in Federal and State court proceedings preferred.
- Experience with Microsoft Office, including Word, Excel, Outlook, and PowerPoint is required, experience with Access preferred.
- Demonstrated ability to identify and determine fraudulent activity and compile necessary documentation in a clear concise manner.
- Demonstrated ability to analyze claims to determine correct processing.
- Demonstrated ability to present complex information in a digestible manner to both internal and external parties, including law enforcement and/or in court proceedings.
- Demonstrated knowledge of broker responsibilities and requirements.
- Demonstrated knowledge of payment methodologies.
- Demonstrated analytical, decision making, and problem-solving skills.
- Demonstrated ability to work collaboratively with multiple partners to positively affect outcomes at the team, organization, and member level.
- Must be detail-oriented with strong organizational skills, including the ability to coordinate workflow.
- Demonstrated ability to provide excellent customer service and develop relationships both internally and externally.
- Demonstrated ability to work with and maintain confidential information.
-
Special Investigator
1 week ago
Capital District Physicians' Health Plan Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigator
2 weeks ago
Capital District Physicians' Health Plan Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigator
3 weeks ago
CDPHP Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigative Analyst
2 days ago
CDPHP Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigator
2 weeks ago
CDPHP Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Corrections and Community Supervision, Department of Albany, United States Full timeMinimum Qualifications DOCCS OSI is seeking qualified candidates to be considered for available openings as an Investigator in one of five OSI divisions. The OSI office location would be determined based upon the needs of the Department and OSI. An Investigator is responsible for ...
-
Special Investigator
3 weeks ago
CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigative Analyst
3 weeks ago
Capital District Physicians' Health Plan Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigative Analyst
3 weeks ago
Capital District Physicians' Health Plan Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigative Analyst
3 weeks ago
CAPITAL DISTRICT PHYSICIANS HEALTH PLAN INC Albany, United StatesGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Special Investigative Analyst
1 month ago
CDPHP Albany, United States Full timeGrounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that off ...
-
Principal Drafting Technician
1 week ago
New York State Albany, United States Full timeDuties Description In the Office of Structures, under the supervision of a Professional Engineer 1, the incumbents may: · • Prepare drawings of moderate to complex difficulty for a variety of structural engineering projects using MicroStation CADD software. · • Prepare and check ...
-
Registered Nurse
5 days ago
Aspire Behavioral Health & DD Services Albany, United States Developmental Disability Services-Primus/T&L/CEM· Job Title: REGISTERED NURSE · Classified__ __ Unclassified__X _ · Unit and Location of Position: · Primus T&L/CEM-Albany GA · Announcement Begin Date: · May 22, 2024 · Announcement Deadline: · Open until filled - subject to close at any time once a satisfactory applicant pool ...
-
Business and Commercial Litigation Associate
3 weeks ago
Gpac Albany, United States Full timeSeeking 2-6+ years' experience Business and Commercial Litigation Associate . This is an amazing opportunity for candidates who are looking to work at a firm that provides a full range of legal services across New York. This is a hybrid remote opportunity. · Please include your ...
-
External Manufacturing Specialist
1 day ago
Regeneron Pharmaceuticals, Inc Albany, United States Full timeWe are currently looking to fill a Specialist position within the New Modalities External Manufacturing (DS/FDS/API) team, specializing in viral vector manufacturing. Regeneron successfully manufactures a range of biopharmaceuticals for patients worldwide, including our approved ...
-
WIFI Engineer
1 week ago
Fusion Technology Albany, United States Full timeJob description · Fusion Technology is in search for an experienced WIFI Engineer for this position based in the Albany, NY area. · Position Title: WIFI Engineer · Pay Rate: $80,000 - $90,000 per year · Location: 3 days per week on-site in Albany, NY and 2 days remote · Incen ...
-
Public Health Sanitarian I
6 days ago
Albany County Albany, United StatesSchedule : Monday–Friday · Hours : 8:30am–4:30pm · Salary Range : $42,000 – $46,500 · Benefits : · Paid time-off · Health, dental, vision · Retirement · Employee assistance program · Tuition reimbursement · To apply: Send resume and cover letter to · About Albany County · A ...
-
Social Service Technician 3
3 weeks ago
Aspire Behavioral Health & DD Services Albany, United States Developmental Disability Services-Primus AlbanyGENERAL NATURE OF WORK: Under limited supervision, provides a broad range of social services to consumers and their families. Conducts consumer intakes, participates in treatment team planning and performs crisis intervention, community support and case management services. Assis ...
-
QC Production Associate I
1 week ago
Actalent Albany, United States Full timeJOB DESCRIPTION NEW OPPORTUNITY WITH GROWING PHARMACEUTICAL COMPANY Laboratory experience required. APPLY TODAY · Description: · The QC/Production Associate I will operate the radiosynthesizers for the production of drug product, as well as operate analytical equipment for th ...
-
Senior Attorney
2 weeks ago
General Services, Office of Albany, United States Full timeMinimum Qualifications This title is part of the New York Hiring for Emergency Limited Placement Statewide Program (NY HELPS)* and applicants must meet the following minimum qualifications to be considered for this position: · This title includes a traineeship opportunity and app ...
Special Investigator - Albany, United States - Capital District Physicians' Health Plan
Description
Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.The SIU Special Investigator will be responsible for investigating complex insurance cases to detect internal and external fraud and abuse. The Special Investigator will research and document cases utilizing resources available to identify suspicious billing patterns and trends. The Investigator will prepare case reports and documents as well as conduct interviews of providers, members, and person/persons with knowledge of the matter under investigation. They will assist in performing audits of providers' claim submissions to assure that services rendered and billed correspond with members' medical records. They are responsible for recognizing violations of CDPHP provider and/or member' contracts/agreements, policies and procedures, and State and Federal laws pertaining to the health care industry. The Special Investigator will coordinate referrals of suspicious instances of fraud and abuse to state and federal agencies as well as assist with negotiating favorable financial settlements on behalf of CDPHP or in preparation of civil suit. The Special Investigator will take an active role in the training of CDPHP employees, providers, and members in the identification and remediation of fraud, waste, and abuse.
QUALIFICATIONS:
CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more. Learn about all CDPHP employee benefits at
As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices on the basis of race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.
CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.
